FM 22-51
LEADERS' MANUAL FOR COMBAT
STRESS CONTROL
HEADQUARTERS, DEPARTMENT OF THE ARMY
DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited
FIELD MANUAL
NO. 22-51
HEADQUARTERS
DEPARTMENT OF THE ARMY
Washington, DC, 29 September 1994
LEADERS' MANUAL FOR COMBAT STRESS CONTROL
DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited.
*This publication supersedes FM 26-2, 29 August 1986.
-------------------------------------------------------------------------------------------------------------------
PREFACE
This field manual (FM) provides information for all leaders and staff on the control of combat
stressors and the prevention of stress casualties. It identifies the leaders' responsibilities for
controlling stress and recognizing the effects of stress on their personnel. It reviews Army
operational doctrine for war and operations other than war. It identifies likely stressors and
recommends actions for leaders to implement for the prevention and management of stress. The
manual describes the positive and negative combat stress behavior associated with stress and
provides leader actions to minimize battle fatigue risk factors. It provides the many different
military branches and disciplines with a common conceptual framework, knowledge base, and
vocabulary so they work together toward controlling stress. It provides information on how
stressors and the stress process interact to improve or disrupt military performance. It identifies
the supporting role of special staffs such as the chaplain and the Judge Advocate General. This
manual also identifies the responsibilities of medical personnel for prevention, treatment, and
management of battle fatigue and stress-related casualties.
The proponent of this publication is the United States (US) Army Medical Department Center
and School (AMEDDC&S). Send comments and recommendations on Department of the Army
(DA) Form 2028 directly to Commander, AMEDDC&S, ATTN: HSMC-FCD, Fort Sam
Houston, Texas 78234-6123.
This publication contains copyrighted material.
Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively
to men.
The use of trade names in this publication does not imply endorsement by the US Army, but is
intended only to assist in the identification of a specific product.
ACKNOWLEDGMENT
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Third
Edition, Revised. Washington, D.C.: American Psychiatric Association, 1987.
CHAPTER 1
OVERVIEW OF COMBAT STRESS
CONTROL
1-1. Introduction
This chapter presents the concept and scope of combat stress control. It reviews historical
experiences with stress casualties in different intensities of conflict and looks et the potential
stressors in high-tech battles. It lists the responsibilities for combat stress control of all junior
(direct) and senior (organizational) leaders, staffs, chaplains, and health care providers. It also
discusses the responsibilities of specialized combat stress control/ mental health personnel.
NOTE
Battle fatigue and misconduct stress behaviors are preventable with strong effective leadership.
1-2. Combat Stress Control
a. Controlling combat stress is often the deciding factor-the difference between victory
and defeat-in all forms of human conflict. Stressors are a fact of combat and soldiers must
face them. It is controlled combat stress (when properly focused by training, unit
cohesion, and leadership) that gives soldiers the necessary alertness, strength, and
endurance to accomplish their mission. Controlled combat stress can call forth stress
reactions of loyalty, selflessness, and heroism. Conversely, uncontrolled combat stress
causes erratic or harmful behavior that disrupts or interferes with accomplishment of the
unit mission. Uncontrolled combat stress could impair mission performance and may
bring disgrace, disaster, and defeat.
b. The art of war aims to impose so much stress on the enemy soldiers that they lose their
will to fight. Both sides try to do this and at times accept severe stress themselves in order
to inflict greater stress on the enemy. To win, combat stress must be controlled.
c. The word control has been chosen deliberately to focus thinking and action within the
Army. Since the same word may have contrasting connotations to different people, it is
important to make its intended meaning clear. The word control is used (rather than the
word management) to emphasize the active steps which leaders, supporting personnel,
and individual soldiers must take to keep stress within the acceptable range. This does not
mean that control and management are mutually exclusive terms. Management is, by
definition, the exercise of control. Within common usage, however, and especially within
Army usage, management has the connotation of being a somewhat detached, numberdriven, higher echelon process rather than a direct, inspirational, leadership process.
d. Stress is the body's and mind's process for dealing with uncertain change and danger.
Elimination of stress is both impossible and undesirable in either the Army's combat or
peacetime missions.
e. The objectives of stress control are as follows:
(1) To keep stress within acceptable limits for mission performance and to
achieve the ideal (optimal) level of stress when feasible.
(2) To return stress to acceptable limits when it becomes temporarily disruptive.
(3) To progressively increase tolerance to stress so that soldiers can endure and
function under the extreme stress which is unavoidable in combat.
f. How can stress be controlled? Stress is controlled in the same ways other complex
processes are controlled.
(1) Monitor the signs of stress and recognize when and if they change. To be
effective, this recognition should come well before the stress becomes disruptive
and causes dysfunction.
(2) Identify and monitor the causes of stress; that is, the stressors. Stress and
stressors are defined in detail in Chapter 2.
(3) Classify the stressors into those which can be controlled (increased, decreased,
avoided, or otherwise changed) versus those which cannot be controlled.
(4) Control those stressors which can be changed by focusing the stress in the
desired direction, either up or down.
(5) Help soldiers adapt to the stressors which cannot be changed.
(6) Learn (and teach) how to directly lower (or raise) the stress level within the
individual soldier as needed, at specific times, in specific situations.
1-3. Scope of Combat Stress Control
Combat stress control is much more than just a few stress reduction techniques which busy
leaders are supposed to learn from books or mental health workers and use now and then when
the stress seems intense. Army combat stress control activities must be a part of everything the
Army does. Combat stress control must be a natural part of the three continuums of Army life:
responsibility, location, and Army mission. Note that a weakness or gap anywhere in these three
continuums can cause weaknesses, overloads, or breakdowns in other aspects of Army life.
a. Responsibility. Responsibility for combat stress control requires a continuous
interaction that begins with every soldier and his buddies. It also involves the soldier's
family members. The interaction continues through the small team's combat lifesaver
(when there is one) and the combat medic. Stress control requires special involvement
from direct(small unit) leaders. The responsibility extends up through the organizational
leaders and their staffs (both officers and noncommissioned officers [NCOs]) at all
echelons. Appendix A describes combat stress risk factors and prescribes leaders' actions
to control them. Leaders, staffs, and individual soldiers all receive assistance from the
supporting chaplains, the medical personnel, and combat stress control/mental health
personnel (see Appendix B for information pertaining to combat stress control units). If
any link in the chain of responsibility is weak, it is the responsibility of the other
members of the chain to strengthen it.
b. Location. The location for combat stress control extends continuously -o
o
o
o
o
o
o
o
From the site of battle, disaster, or rigorous duty.
Through the unit's forward and rearward support areas.
Through the communications zone (COMMZ), if present.
To the continental United States (CONUS).
To the unit's home station.
To the rear detachment.
To the family support group.
To the Army hospitals and medical centers.
The location even extends to the Department of Veterans Affairs and veterans
organizations after the soldiers' discharge, medical separation, or retirement. Preventive
efforts, and also treatment for stress dysfunction, should be actively accomplished at each
location. If stress control is weak at any one location, this can cause stress and breakdown
not only there, but elsewhere in other locations.
c. Army Missions. The Army operations that require combat stress control are all
inclusive. They extend continuously -o
o
o
o
From garrison maintenance activities.
To peacetime training exercises.
To operations other than war.
To war.
o
To the integrated battlefield.
The same basic stress control principles apply across the entire range of Army operations.
Within our rapidly changing world, many Army units have had their missions shift across
a wide range of operations in a matter of weeks, sometimes with little advance warning.
Individual soldiers, family members, unit leaders and staffs, chaplains, and medics
(including the mental health/combat stress control teams) must be involved and work
together continuously. They must practice stress control against the frequent minor
stressors and the occasional severe stressors of peacetime. This, and only this, enables
them to be ready on short notice for the extreme stressors of war.
1-4. Historical Experience
Concept.
a. Origins of the Combat Stress Control
(1) Combat stress control is not new.
The basic leadership techniques which this manual will review were discovered
and taught by successful military leaders through the centuries and have long been
cornerstones of US Army leadership training. Combat stress control medical
doctrine for preventing and treating stress casualties is sometimes mistakenly said
to have originated from the Israeli Defense Force experiences in the 1970s and
1980s. Quite the contrary, the US Army learned that basic doctrine from its allies
during World War I (WWI).
(a) The French and British discovered that if stress casualties were
evacuated far to the rear, many became chronic psychiatric cripples. If
treated quickly close to their units, most recovered and returned to duty.
The US Army Surgeon General of that time recommended that we adopt a
three-echelon system for prevention, triage, treatment, and return to duty
of stress casualties.
1. First echelon. The US Army attached a trained psychiatrist to
each division. The psychiatrist's role was to advise command in the
prevention of stress casualties, to screen out the unsuitable, and to
assure that overstressed soldiers were rested and returned to duty
within the division whenever possible. Following British practice,
stress casualties in the division were labeled "Not Yet Diagnosed,
Nervous" (NYDN). This avoided even the suggestion of physical
injury implied by the dramatic popular label "shell shock" or the
implication of psychiatric illness conveyed by the official
diagnosis of "war neurosis." Under good conditions, 70 percent of
stress casualties were returned to duty within the division.
2. Second echelon. Behind the divisions in WWI, the US Army had
specialized neurological hospitals ( 150 beds) whose sole function
was to provide additional brief rest and rehabilitation to those
NYDN cases whom the division psychiatrist was unable to return
to duty. These neuropsychiatric facilities also provided brief rest
and rehabilitation to persistent cases of "gas mania" or "gas
hysteria" who believed they had suffered chemical injuries, even
though they had not been truly injured. About 55 percent of the
cases sent to these facilities returned to duty in an average of two
weeks.
3. Third echelon. Further to the rear was a specialized base hospital
which provided several weeks of additional treatment for cases
who failed to improve in the neurological hospital. It returned
many of those cases to useful duty.
(b) The three-echelon system worked well, but on occasions when the
tactical situation interfered with forward treatment, it clearly showed the
superiority of the forward deployed part of the program.
(2) The experience of WWI was forgotten between wars. It had to be rediscovered
in World War II (WWII) after several disastrous experiences when large numbers
of psychiatric casualties were overevacuated in the early battles. By late WWII in
the European and Mediterranean theaters, all divisions again had a division
psychiatrist with mental health assistants. The psychiatrist supervised a Training
and Rehabilitation Center in the division rear. The psychiatrists trained and
supervised the regimental and battalion surgeons in recognizing and treating
combat exhaustion or battle fatigue cases. Most regimental combat teams
(equivalent to our brigades) had an exhaustion center in the regimental trains area.
Many battalions maintained a rest area at the battalion field kitchens. The
surgeons supervised these facilities to assure that soldiers who were rotated back
to them recovered quickly and returned to duty. Behind the division there were
specialized clearing companies commanded and staffed by psychiatrists. These
clearing companies provided additional treatment for nonresponders or problem
cases. Specialized base hospitals were located in the COMMZ.
(3) Following WWII, the lessons learned were embodied in a table of
organization and equipment (TOE) unit, the mobile psychiatric detachment, or
"KO" team. These teams functioned very effectively in Korea.
b. Experience in War.
(1) In the WWII Mediterranean and European theaters, the average incidence of
combat exhaustion casualties was one case requiring medical holding and
treatment for every four wounded in action (WIA) (a 1:4 ratio). In really intense
or prolonged fighting, the ratio rose to 1:2. On the Gothic line in Italy, the 1st
Armored Division suffered 137 combat exhaustion casualties for 250 WIA (a
1:1.8 ratio). Overall, with the correct treatment, 50 to 70 percent of combat
exhaustion casualties returned to combat within 3 days, and most of the remainder
returned to useful duty within a few weeks.
(2) During WWII the 6th Marine Division was involved in the Battle of Okinawa.
They fought day after day and were up against a determined, dug-in Japanese
resistance, rain and mud, and heavy artillery. The division suffered 2,662 WIA
and had 1,289 combat exhaustion casualties (a ratio to WIA of 1:2). Many of the
combat exhaustion cases were evacuated to Navy ships offshore and few of those
cases ever returned to duty.
(3) In the Pacific theater in WWII, there was about one neuropsychiatric casualty
evacuated from the theater for every one WIA (a 1:1 ratio). Many of these troops
appeared psychotic (bizarrely out of touch with reality). Most of these, however,
did not come from the combat units or areas. They were combat service support
(CSS) troops left behind by the war on the hot jungle or coral islands or the cold,
damp Aleutian Islands. The stressors were the combination of isolation,
monotony, boredom, chronic discomfort, and low-grade illness from the
environment, plus fear of disease, injury, and surprise attack. In retrospect, it was
realized that evacuating these bizarre stress reaction cases home only encouraged
more soldiers to "go crazy" when they temporarily reached their limit of tolerance
to stress. It would have been better to have sent them to rest camps close to their
units. This might have returned the majority quickly to duty, as was done with the
combat exhaustion cases in the European and Mediterranean theaters.
(4) It was also shown in WWII that tough training and esprit de corps prevented
many battle fatigue casualties. Elite units, such as the ranger and airborne units,
had less than one battle fatigue casualty for every ten WIA. This unit
cohesiveness prevailed even in combat assaults, such as Normandy and Arnhem,
where extremely high casualties were suffered. Unit cohesiveness also prevailed
during prolonged fighting like the Battle of the Bulge.
(5) During the Yom Kippur War (1973), the Israeli experience confirmed the risk
of stress casualties in the modern, high-tech, continuous operations (CONOPS)
battle. The Israelis counted on the high cohesion and training of their troops and
leaders to keep stress casualties to a minimum. They were caught, however, by
strategic and tactical surprise and were forced to mobilize on a religious (fasting)
holiday. They sent their reserves piecemeal into battle. Their Arab opponents,
whom they had previously discounted as inefficient, used massed artillery, armor,
and wire-guided missiles. The Arab units followed the Soviet CONOPS,
echeloned-attack doctrine. Israeli estimates of stress casualties suggest that large
numbers of Israeli soldiers, including veterans and leaders, became unable to
function solely because of stress. Stress casualties were frequent in the Golan
Heightsfighting, in the initial defense of the Sinai, and during the recrossing of the
Suez Canal. Since the Israeli Defense Force had no plans for treatment and return
to duty, all such cases were evacuated to hospitals in Israel. True to the experience
of WWI and WWII, many of these Israeli soldiers who were evacuated remain
psychiatrically disabled today.
(6) After the 1973 war, the Israelis instituted a model program of leadership
training and medical/mental health support. This was intended to prevent combat
stress casualties and to treat those cases which occurred in the brigade and
division support areas. However, in the 1982 Lebanon invasion, many cases were
inadvertently evacuated by helicopter to Israel in the initial haste of the invasion.
Few of these cases returned to full duty, while 60 to 80 percent of those treated in
Lebanon did.
(7) One Israeli armored battalion trapped in a desperate night action against the
Syrians had approximately 30 combat stress cases and 30 WIA (a 1:1 ratio). A
combat engineer battalion which was accidentally bombed by an Israeli fighterbomber had approximately 25 killed in action (KIA) and 200 WIA. This same
battalion soon had 20 immediate combat stress casualties. Approximately 25 other
soldiers developed delayed stress reactions over succeeding days (a ratio to WIA
of 1:4.4). Even the Israelis' strong preventive program could not completely
prevent battle fatigue casualties in a high-tech war.
c. Experience in Vietnam.
(1) In Vietnam, battle fatigue casualty rates rarely exceeded one per ten WIA. The
reasons for the few battle fatigue casualties included the sporadic nature of
fighting and our air and artillery superiority. Other factors were well-supplied fire
bases, scheduled rest and recuperation (R&R), and a fixed combat tour. All these
factors kept most battle fatigue cases at levels which could be treated in their units
and did not require medical holding or hospitalization.
(2) Other behavioral problems related to loneliness and frustration, however, were
associated with combat stress in Vietnam. Serious incidents of poor discipline
occurred, including commission of atrocities at My Lai(March 1968), combat
refusal, and even "fragging" (murder) of leaders. These events threatened unit
cohesion and the chain of command. By 1970-1971, when US ground forces were
rarely committed to offensive operations, "neuropsychiatric casualties," especially
drug and alcohol abuse and addiction, became epidemic. By September 1971,
neuropsychiatric cases accounted for over 60 percent of all medical evacuations
from the theater. Today those misconduct problems are recognized as having
contributed to the high incidence of delayed posttraumatic stress disorder (PTSD)
in Vietnam veterans. Due to the different nature of the stress, these types of
misconduct stress behaviors are more likely than battle fatigue in operations other
than war (conflict). These misconduct stress behaviors can seriously undermine
the objectives and successes of the mission.
d. Experience in Catastrophic Events During Peacetime and Operations Other Than
War. Within the past few years, numerous accidents and hostile incidents have
demonstrated the value of crisis stress control for soldiers, their families, and civilians
caught in the turmoil of peacetime operations. Some recent historical events are listed in
Table 1-1. Unit leaders aided by post and hospital mental health personnel, chaplains, and
others played key roles in providing crisis stress control for many of these tragic
incidents. In the peacetime military, as in civilian police, fire, and disaster relief, stress
debriefing of critical incidents has proved its value in preventing and treating disabling
PTSD.
1-5. Effects of Battle on Soldiers, Units, and Leaders
a. War is fundamentally a contest of wills fought by men, not machines. Ardant Du Picq,
a 19th century French officer and student of men in battle, reminded us that, 'You can
reach into the well of courage only so many times before the well runs dry." Even before
that, Marshall De Saxe, writing in the 18th century, pointed out that, "A soldier's courage
must be reborn daily," and went on to say that the most important task of leaders was to
understand this, to care for and prepare soldiers before battle, and to use tactics during
battle which recognize that courage must be renewed.
b. Commanders must understand that in battle men and units are more likely to fail
catastrophically than gradually. Commanders and staffs, assisted by combat stress control
personnel, medics, chaplains, and others, must be alert to subtle indicators of fatigue,
fear, poor discipline, and reduced morale. They must take measures to deal with these
symptoms before their cumulative effects cause a unit to collapse. Staffs and
commanders at higher levels must be advised about the impact of intense or prolonged
combat on subordinate units. Military organizations can fight at peak efficiency for only
so long. Prolonged demands of combat cause efficiency to drop even when physical
losses are not great.
c. A unit may not be capable of performing its mission adequately if soldier resources are
depleted because -o
o
o
o
o
o
o
Vigilance deteriorates.
Determinations and calculations become inaccurate.
Reports become faulty.
Decisions become slow and inaccurate.
Orders are misunderstood/forgotten.
Weapons are misused/underused.
Maintenance and preplanning are forgotten.
Table 1-1. Examples of Catastrophic Events During Peacetime and Operations Other Than War
- Historic Incidents
o
o
o
o
Maintenance and preplanning are forgotten.
Motivation to perform duties decreases.
Leaders' effectiveness decreases.
Training becomes ineffective.
d. Degradation of soldiers' performance means that they lose a portion of their normal
effectiveness. Continuous, unrelieved operations and excessive stress degrade
performance and erode soldier resources. Combat capability is cut whether the unit is at
50 percent strength or at full strength with soldiers who are only 50 percent effective. As
individual and unit capabilities fall, battle fatigue may contribute not only to more battle
fatigue casualties but also to higher rates of wounds and disease and nonbattle injuries
(DNBI).
e. The skill and courage of leaders at all levels are critical to success in operations across
the full range of conflict. The chaos of combat places a premium on initiative, unit
cohesion, and mental and physical preparedness of soldiers and units. While the
importance of winning the first battle is great, the ability to fight sustained campaigns is
vital to deterrence and to victory. In war, temporary battle fatigue casualties are
inevitable but can be treated and returned to duty in or close to their units. In operations
other than war (conflict), the enemy threat counts on psychological stress and misconduct
stress behaviors to disable the defender. In operations other than war (conflict), drug and
alcohol abuse, other violations of military discipline, and criminal acts must be prevented
by strong leadership. Misconduct stress behaviors are dealt with through the legal system.
Medical care and treatment are provided when necessary.
1-6. The Potential High-Tech Battlefield
United States Army planners have predicted what future high-tech combat could entail. This was
demonstrated in the recent past with the world's confrontation with Iraq over the seizure of
Kuwait. Based on the current world situation, such future battles are not unthinkable. The
unprecedented debilitating effects of battlefield in the twenty-first century will demand even
more attention to the preparation of soldiers, crews, and leaders for combat hardships. In such
battlefields, the soldier will face many challenges.
a. Challenge of Isolation. The first challenge is isolation. Units may experience periods of
combat where forces are intermixed and lines of communication are broken. Units will
experience feelings of uncertainty and helplessness from unpredictable strikes by longrange weapon systems. To make matters worse, these strikes may be inflicted by one's
own forces in the confusion of battle. The certain use of smoke and obscurants will limit
soldiers' vision, promoting feelings of separation, abandonment, and vulnerability.
b. Challenge of Higher Rates of Casualties from Conventional, Nuclear, Biological, and
Chemical Weapons/Agents. The increased rate of destruction of potential future
weaponry has both physical and psychological effects. Losing 40 to 60 percent of an
entire unit in minutes or hours could leave the remaining soldiers incapacitated. The rapid
and horrible death of their comrades and leaders could have a definite and detrimental
effect on the mental stability of the unit. Surviving soldiers will have to be prepared to
overcome the experience of mass human destruction. They will need to be trained to take
over from those lost and to reshape units that can continue to fight.
c. Challenge of Human-Technological Imbalance. The emergence of new technologies
has significantly increased the range of weapons, reduced reaction time, and changed
conditions over which battles are fought. This new technology has the potential to exceed
the capacity of human crews to fight.
o
o
All-weather, day-and-night capable vehicles which can operate for extended
periods without resupply are limited only by the crews' need for sleep.
High-probability-of-kill, direct fire systems will be degraded over time by the
stress and fatigue levels of the men aiming those weapons.
o
o
Improved sensors and longer range weapons could exceed the capabilities of a
tactical headquarters to plan and execute battles fought over expanded areas of
operations.
Short engagement times and the increased lethality of new weapons could
overwhelm the ability of staffs to control and coordinate the overall battle.
Soldiers, leaders, and staffs will face problems of reduced efficiency effectiveness when
fighting over extended periods. These conditions will tend to neutralize the potential gain
s of new war-fighting technologies and force new approaches to the preparation and
employment of soldiers, leaders, and staffs.
d. Challenge of the Mental Rigors of Combat. Armies must initiate training programs to
help precondition soldiers to the mental rigors of combat. This is of vital importance as
the potentially catastrophic effect of battle stress in future warfare becomes evident. The
military force that does this best will have a decided edge in any war. Future combat will
strain human endurance to unprecedented levels. If these challenges are left unchecked
by poor mental and physical conditioning of soldiers, they could result in the disastrous
failure of entire units. Failure to consider the human factors in an environment of
increased lethality and uncertainty could cause a nation's concept of warfare to be
irrelevant. With the miniaturization and spread of high-tech (and perhaps even of nuclear,
biological, and chemical [NBC]) weapons, this can be just as true in operations other than
war (conflict) as in war.
1-7. Responsibilities for Controlling Combat (Conflict) Stress
a. Unit Cohesiveness Development. Rigorous, realistic training for war must go on
continuously to assure unit readiness. Emphasis must be placed on establishing and
maintaining cohesive units. Unit training and activities must emphasize development of
soldier skills. This development should focus on building trust and establishing effective
communication throughout the unit.
b. Senior (Organizational) Leaders' Responsibilities. The chain of command must ensure
that the standards for military leadership are met. Senior leaders must provide the
necessary information and resources to the junior leaders to control combat stress and to
make stress work for the US Army and against the enemy. Senior leaders' responsibilities
are listed in Table 1-2.
c. Junior (Direct) Leaders' Responsibilities. Junior leaders, and especially the NCOs,
have the crucial business of applying the principles of stress control day-by-day, hour-byhour, minute-by-minute. These responsibilities overlap with senior leaders'
responsibilities but include parts that are fundamentally "sergeants' business," supported
by the officers.. See Table 1-3, page 1-11, for junior leaders' responsibilities.
d. Staff Section Responsibilities. Each element of the commander's staff (adjutant,
intelligence, operations, logistics, and civil and public affairs [if present]) has its own
area of responsibility that has particular relevance to stress control (see Table 1-4, pages
1-12--13). For example, the adjutant's responsibility for mail and decorations is more
than just "nice to have." These are important stress control measures. Morale, welfare,
and recreation opportunities, and even the use of Army bands, are valuable ways to
sustain morale and combat readiness. For additional information on the role of Army
bands, see Appendix C.
Table 1-2. Senior Leaders' Responsibilities
Table 1-3. Junior Leaders' Responsibilities - Combat Stress Control
Table 1-4. Staff Responsibilities for Combat Stress Control
Table 1-4. Staff Responsibilities for Combat Stress Control (Continued)
e. Chaplains' Responsibilities. Chaplains, especially those in unit ministry teams, have
extremely important responsibilities. See Table 1-5 for chaplains' responsibilities. For
additional information on the unit ministry teams, see Appendix D.
f. Unit Medical Personnel's Responsibilities. Unit medical personnel assist commanders
and NCOs in the control of stressors. See Table 1-6, page 1-16, for combat stress control
responsibilities.
1-8. Primary Responsibility-Combat Stress Control/Mental Health Personnel
Combat stress control is the primary responsibility-in peace as well as in war-of the mental
health team. While the chain of command and NCO chain of support have ultimate responsibility
for stress control, the unit leaders must give primary attention to accomplishing their unit's
mission. Headquarters staffs and unit chaplains and medical personnel also have other primary
missions which must come first. Sustaining military performance, preventing stress casualties,
and treating stress symptoms are the primary missions for Army combat stress control units and
personnel.
a. Combat Stress Control Organization. As defined in Army Regulation (AR) 40-216, the
mental health team consists of Army psychiatrists, clinical psychologists, social work
officers, occupational therapy officers, psychiatric nurses, and their enlisted counterparts.
Mental health personnel are organized into organic mental health sections in the main
support medical companies of divisions and the medical companies of separate brigades.
In both the corps and the COMMZ, the mental health sections are organic to the area
support medical battalion. Mental health staff sections in the medical command, medical
brigade, and medical group monitor and coordinate combat stress control support. The
medical combat stress control units (companies and detachments) are a corps and
COMMZ asset. They are designed to divide into mobile, modular combat stress control
teams. The teams provide combat stress control support throughout the corps and
routinely deploy forward to reinforce mental health section personnel in the division and
brigade areas. The philosophy and the organizational and operational concept for combat
stress control are reviewed in Appendix B.
b. Combat Stress Control /Mental Health Team Responsibilities. Table l-7, page l-17,
summarizes the mission and responsibilities of combat stress control/mental health
personnel in combat stress control.
1-9. Effective Combat Stress Control Program
Without an effective combat stress control program, combat stress can be a "war-stopper" for our
soldiers. This may be by way of a high number of battle fatigue casualties during and after
intense critical battles. It may be by way of misconduct stress behaviors which undermine the
objectives and the will to persist in operations other than war (conflict). Maximizing the amount
of combat stress experienced by our forces is one of the main objectives of the enemy. An
effective combat stress control program requires participation at all levels. It is implemented by
command authority. It is supported by commanders, leaders, staffs, chaplains, physicians, and
health care providers and should be facilitated by mental health/combat stress control personnel
and units. Through these actions we can control the effects combat stress has on the
accomplishment of unit missions by -


Identifying and controlling stress factors (stressors).
Reducing number of battle fatigue casualties and misconduct stress behaviors.
Reducing recovery time for battle fatigue casualties.
An effective combat stress control program focuses the effects of combat stress toward
increasing positive stress responses while decreasing disruptive stress. It reduces the possibilities
of stress becoming a war-stopper for the US.
Table 1-5. Chaplains' Responsibilities for Combat Stress Control
Table 1-6. Unit Medical Personnel's Responsibilities for Combat Stress Control
Table 1-7. Combat Stress Control Unit and Mental Health/Combat Stress Control Personnel's
Responsibilities
CHAPTER 2
STRESS AND COMBAT PERFORMANCE
Section I. STRESS TERMINOLOGY AND THE STRESS CONCEPT
2-1. Introduction
The understanding of the stress process has been refined over time by research and experience,
leaving some terms obsolete. This chapter establishes how the Army's combat stress control
concept currently defines and interprets stress terminology.
2-2. Understanding of Interactions
a. Stressors. A stressor is any event or situation which requires a nonroutine change in
adaptation or behavior. Often it is unfamiliar or creates conflict among motives within the
individual. It may pose a challenge or a threat to the individual's well-being or selfesteem. Stressors may be positive or negative (for example, promotion to new
responsibilities or threat of imminent death).
b. Combat Stressors. Combat stressors are any stressors occurring during the course of
combat-related duties, whether due to enemy action or other sources. Combat duties do
not necessarily involve being shot at and may be carried on even in "safe" areas far from
the enemy. Many Stressors in combat duties come from the soldier's own unit, leaders,
and mission demands. They may also come from the conflict between mission demands
and the soldier's home life.
c. Stress. Stress is the internal process of preparing to deal with a stressor. Stress involves
the physiological reflexes which ready the body for fight or flight. Examples of those
reflexes are increased nervous system arousal, release of adrenaline into the bloodstream,
changes in blood flow to different parts of the body, and so forth. However, stress is not
synonymous with arousal or anxiety. Stress involves physical and mental processes
which, at times, suppress arousal and anxiety. Stress also involves the accompanying
emotional responses and the automatic perceptual and cognitive processes for evaluating
the uncertainty or threat. These automatic processes may be instinctive or learned.
d. Stress Appraisal. Stress may or may not involve conscious awareness of the threat, but
the stressor must be perceived at some level to cause stress. The amount of stress
experienced depends much on the individual's appraisal of the stressor and its context,
even if that appraisal is wrong. The stress process includes psychological defenses which
may filter the perception and appraisal to shield the individual from perceiving more
threat than he is ready to tolerate.
e. Physical Stressors Versus Mental Stressors. A distinction can be made between those
Stressors which are physical and those which are mental.
(1) A physical stressor is one which has a direct effect on the body. This may be
an external environmental condition or the internal physical/physiologic demands
of the human body.
(2) A mental stressor is one in which only information reaches the brain with no
direct physical impact on the body. This information may place demands on either
the cognitive systems (thought processes) or the emotional system (feeling
responses, such as anger or fear) in the brain. Often, reactions are evoked from
both the cognitive and the emotional systems.
f. Stress Behaviors. These are stress related actions that can be observed by others; for
example, moving or keeping still, speaking or not speaking. The behaviors may be
intended to overcome and turn off a stressor, to escape it, or to adapt to it. They may
simply reflect or relieve the tension generated by the internal stress process. Any of these
different types of stress behavior may be successful, unsuccessful, or not influence the
stressful situation at all. They may make the stressor worse. They may resolve one
stressor but create new stressors.
g. Combat Stress. This is the complex and constantly changing result of all the stressors
and stress processes inside the soldier as he performs the combat-related mission. At any
given time in each soldier, stress is the result of the complex interaction of many mental
and physical stressors.
2-3. Discussion of Physical Versus Mental Stressors
a. Table 2-1 gives examples of the two types of physical stressors (environmental and
physiological) and the two types of mental stressors (cognitive and emotional).
Table 2-1. Types of Physical and Mental Stressors
b. The physical stressors evoke specific stress reflexes. For example, cold causes
shivering and decreased blood flow to skin and extremities; heat causes sweating and
increased blood flow to skin. These stress reflexes can maintain internal balance and
comfort up to a point but then may be exceeded.
c. The distinction, however, between physical and mental stressors is rarely clear cut.
(1) Mental stressors can also produce the same stress reflexes as do some physical
stressors; for example, decreased blood flow to skin, increased sweating,
adrenaline release, and pupil size. These reflexes can markedly increase or
decrease the individual's vulnerability to specific physical stressors. The mental
stressors also presumably cause changes in brain chemistry (involving the
neurotransmitter chemicals in the brain).
(2) Physical stressors are also mental stressors when they provide information to
the brain which creates a mental demand or poses a threat to well-being. Even if a
physical stressor is not a threat to life and health, the discomfort, distraction, and
performance degradation it causes may be emotionally upsetting. Therefore,
physical stressors, too, can produce the nonspecific arousal reflexes. Heat, cold,
dehydration, toxic chemicals, and other physical stressors can also interfere
directly with brain functioning; they can impair perceptual and cognitive mental
abilities, thus increasing the stresses. Light, noise, discomfort, and anxiety
provoking information may interfere with sleep, which is essential to maintain
brain efficiency and mental performance over time.
d. Because of this intermeshing of physical and mental stressors and stress reflexes, no
great effort needs to be invested in distinguishing them in military contexts until the
physical stressors and stress reflexes become so severe that they warrant specific (and
perhaps emergency) protective measures and treatment. Prior to that stage, unit leaders
and medical and mental health personnel should assume that both physical and mental
stresses are usually present and interacting within all unit personnel. Guidelines for
controlling both physical and mental stressors at the same time should be contained in the
tactical standing operating procedure (TSOP), if possible.
2-4. Positive Stress
a. Stress is not necessarily bad or harmful. Positive stress (or eustress) is that degree of
stress which is necessary to sustain and improve tolerance to stress without overdoing the
stress experience. Some level of stress is helpful and even necessary to health. This is
especially clear for some physical stressors to which the body can acclimatize. To
achieve greater tolerance or acclimatization to a physical stressor, a progressively greater
exposure is required. This exposure should be sufficient to produce more than the routine
stress reflexes. Well-known examples of acclimatization are heat acclimatization,
cardiovascular (aerobic) fitness, and muscle strength. These examples are so important to
combat stress control that they are worth reviewing. The process of improving tolerance
to stressors through progressive exposure to those stressors will also be true of cognitiveemotional stressors.
(1) Heat acclimatization. You cannot become fully acclimatized to heat by just
lying around in hot conditions. You have to perform physical exercise in the heat
to stress the body's temperature regulation system. At first, the body may
overreact with excessive sweating and heart rate. As acclimatization occurs, the
body becomes more efficient at cooling itself. However, acclimation has a
maximum level. If you stop exercising in the heat, you will gradually lose the
acclimatization you have gained. Mission-oriented protective posture (MOPP)
training should be considered as a part of the acclimatization program.
(2) Aerobic fitness. It is well known that you can become aerobically fit only by
exerting yourself to progressively greater degrees of physical effort. One way is to
enter into 20-minute (or more) exercise programs of jogging, running, bicycling,
swimming, or special aerobic exercises each day. Any physical effort which
sufficiently raises heart rate and respiratory rate and works up a sweat for 20
minutes or more will increase your tolerance. In other words, you must stress the
system. After doing that for several days, the same effort raises heart rate and
sweating only a little. You become less short of breath, and the effort seems much
easier. To become more aerobically fit, you have to increase the work stressor
even more until the body again shows the stress of increased heart rate, shortness
of breath, and sweating. If you stop exercising aerobically for weeks or months,
your improved aerobic fitness will gradually be lost.
(3) Muscle strength. Body builders increase their muscle mass by lifting
progressively heavier weights or working against progressively greater resistance
on exercise machines. In order to increase muscle strength, you have to increase
the stressor (the weight lifted) and the stress (the physiological increased effort
within the muscle cells). After the muscle has become accustomed to lifting a
given weight, it no longer seems like a great effort. There is little stress taking
place in the muscle. The muscle will merely maintain its strength and not get any
stronger with repeated exposure. If you stop doing even that amount of lifting,
your muscles will get flabby again over time. A good maxim is, "If you do not use
it, you will lose it."
b. It is important to understand that stressors which overstrain the adaptive capability of
the body (whether or not they cause pain) do not hasten acclimatization or increase
tolerance to the stressor. They often retard it and may even permanently impair future
acclimatization. Consider the examples of the physical stressors discussed above.
(1) Heat acclimatization is not speeded by getting heat cramps or heat exhaustion.
Neither is it significantly slowed, although the person's self-confidence and
motivation to try again may be impaired. However, people who are driven to the
stage of heatstroke and survive will forever be physically less tolerant to heat.
They will be more likely to develop heatstroke in the future if exposed to heat.
(2) Runners or body builders who push too hard early in training may not feel
severe pain at the time. Hours later, however, they may develop muscle swelling,
ache, and stiffness. At best, this will take days to recover to the point where the
athlete can even continue with the exercise regimen. At worst, the damaged
muscles may break down and release the substance myoglobin into the
bloodstream which can permanently damage or destroy the kidneys. Excessive
painful stress on bones, joints, and ligaments does not make them grow stronger
but instead causes stress fractures, sprains, tears, and other damage that may
require months of reduced activity to heal.
(3) The issue for the master fitness trainers is how to keep the physical work
stressors and stress in the positive or eustress range which increases strength and
fitness. They must control the stressors and stress so they are not extreme-too
little or too much.
<>
WARNING
Unconditioned, unacclimatized troops should not be overextended in training
as this could cause severe injury or even death. A special physical training
program will be required.
c. Positive stress also applies to mental stressors (cognitive and emotional), as well as to
physical stressors (environmental and physiological). Appropriate exposure to mental/
emotional stressors is necessary to increase tolerance to them.
(1) Armies have known for centuries about the positive effects of stress in
preparing soldiers for combat. In old-style basic training (prior to 1970), the drill
sergeant deliberately made himself more fearsome than death itself so that the
trainee would learn to respond automatically, even in a state of terror. That
technique is not useful today because modern war requires more small unit
cohesion, trust between leaders and those led, and initiative even on the part of the
junior enlisted soldier. The modern drill sergeant must, instead, require the
trainees to meet difficult (stressful) standards and work with the trainees to assure
that they master them. The result is a well-earned sense of confidence in self,
comrades, and leaders that can be applied to future demands.
(2) The Army knows that airborne and air assault training are not just intended to
teach the skills needed to arrive on a battlefield after jumping from a low-flying
aircraft or repelling from a helicopter. Their greater value comes from requiring
soldiers to confront and master their extremely strong, instinctive fear of heights
under circumstances which are deliberately stressful at the time. During training,
this fear builds self-confidence and a sense of special identity on completion. (In
fact, the training itself is not exceedingly dangerous, statistically speaking.
However, the possibility of death does exist if you are extremely unlucky or fail
to do the task correctly. This can contribute to additional stress.)
(3) Ranger school is a clear example of the Army's recognition of the benefits of
positive stress. A generic ranger course objective would read: Perform complex
and difficult physical and mental task under great pressure, sleep loss, water and
food deprivation, and physical fatigue. No one coasts through ranger school. If
anyone seems to be coasting through, the trained ranger cadre will increase the
demand on that person until he, too, reaches the stage of stress where he realizes
he cannot get through it all alone. Ranger school teaches small teams and their
rotating leaders how to control stress in all the team members so the team
accomplishes the mission. The training gives the individual soldier confidence,
but even more, an awareness of how stress works in oneself and others. It teaches
stress control, not stress reduction. Often the need for the team and its individual
members is to play different mental and physical stressors against each other. This
is done by increasing some stressors while decreasing others to keep the team on
its mission and to keep individual soldiers from giving up.
d. To some degree, acclimatization to mental (cognitive/emotional) stressors also shares
that "use it or lose it" feature which is true for adaptation to physical stressors. The
airborne qualified trooper may experience more unpleasant stress symptoms when
jumping after not having jumped for many months. The physician may find the stress
unexpectedly higher when performing a potentially risky patient-care procedure that was
once so frequently practiced that it had seemed to involve no stress at all but which has
not been performed for some time. However, the memory of successfully mastering the
stressor in the past usually speeds up the return of adaptation.
e. Tolerance to mental stressors is increased by successfully facing and mastering similar
stressors (just as tolerance to physical stressors is). However, being overwhelmed by
emotional or mental stress may temporarily or permanently impair future tolerance (just
as exceeding the ability to cope with physical stressors may). Up to a point, mental stress
(even uncomfortable mental stress) may increase tolerance to future stress without any
current impairment. A higher level may cause temporary overstrain but may heal as
strong or stronger than ever with rest and restorative processing. More severe overstrain,
however, may permanently weaken tolerance to future mental stress. As with some cases
of damage from physical stress, the harm done by mental stress may not be apparent at
the time. It may only be apparent later. There is reason to believe that immediate
preventive measures or treatment can greatly reduce the potential for chronic disability,
even in cases of extreme emotional overstrain.
2-5. Relationship of Stress to Task Performance
Stress is an internal process which presumably evolves because it helps the individual to function
better, stay alive, and cope successfully with stressors. However, there is an optimal range of
arousal (or motivation or stress) for any given task.
a. If there is too little arousal, the job is done haphazardly or not at all because the
individual is easily distracted, makes errors of omission, or falls asleep. If arousal
becomes too intense, the individual may be too distractible or too focused on one aspect
of the task. He may have difficulty with fine motor coordination and with discriminating
when and how to act. If the individual is unfamiliar with his own stress reflexes and
perceives them as dangerous (or incapacitating, or as a threat to self-esteem), the stress
itself can become a stressor and magnify itself.
b. With extreme arousal, the individual may freeze (become immobile or petrified by
fear). Alternately, he may become agitated and flee in disoriented panic. If stress persists
too long, it can cause physical and mental illnesses. Extreme stress with hopelessness can
even result in rapid death, either due to sympathetic nervous system overstimulation
(such as stroke or heart attack) or due to sympathetic nervous system shutdown (not
simply exhaustion). An individual giving up can literally stop the heart from beating.
c. The original purpose of the stress reaction was to keep the person alive. The military
requirement for the stress process is different. It is to keep the soldier in that range of
physiological, emotional, and cognitive mobilization which best enables him to
accomplish the military mission, whether that contributes to individual survival or not.
This optimal range of stress differs from task to task. Tasks which require heavy but
gross muscular exertion are performed best at high levels of arousal (Figure 2-1). Tasks
that require fine muscle coordination and clear thinking (such as walking point on a
booby-trapped jungle trail, or distinguishing subtle differences between friendly and
enemy targets in a night-vision gun sight) or that require inhibiting action (such as
waiting alertly in ambush) will be disrupted unless the stress process is kept finely tuned.
If the stress process allows too much or too little arousal or if arousal does not lessen
when it is no longer needed, stress has become harmful.
2-6. Fatigue
Fatigue means weariness and/or decreased performance capability due to hard or prolonged work
or effort. It reflects the stage where the energy mobilized by the stress process is beginning to run
down. If the effort continues, the fatigue can build to the point of exhaustion.
a. Fatigue can be produced by both physical and mental tasks. A well-known example of
physical fatigue is muscle tiredness. This can be limited to specific muscles which have
been overworked. Another example is aerobic fatigue (where the whole body is short of
oxygen and perhaps blood sugar, is probably overheated, and is wanting to rest).
Figure 2-1. Change in performance with increasing arousal (stress) for two types of tasks.
b. Sleep loss produces a different kind of fatigue which is primarily mental. The sleepdeprived person has trouble keeping his mind focused although he has no decrease in
muscular or aerobic work capacity. People with sleep-loss fatigue usually appear tired
and slowed down, or they may also be speeded up, hyperactive, and irritable.
c. Continued mental effort on a specific task, whether it is a task requiring much thinking
or constant attention, produces mental fatigue. That is, performance gets progressively
worse with time, and the person wishes he could stop to do something else. Even a few
minutes of break, while the mind does some quite different mental tasks, substantially
relieves the mental fatigue and improves the performance.
d. Physical illness can also bring on fatigue. People who have ever had the flu or even
just a cold know how quickly one tires. They only want to rest or sleep.
e. Intense emotions also produce fatigue. This is especially true of anxiety and fear
because they arouse the fight or flight reflexes of the physical stress process. This will be
discussed later in justifying the use of the term battle fatigue.
f. The level of fatigue experienced may be influenced by -o
o
o
o
Work intensity.
Task difficulty.
Duration of sustained effort.
General well-being of the individual.
Fatigue can also be influenced by the level of preparedness to perform the specific task.
(1) For physical fatigue: A marathon runner may have strong legs, superb aerobic
fitness, great health, and self-confidence, but too little arm and shoulder strength
to be able to chin himself even once before being stopped by fatigue.
(2) For emotional fatigue: A healthy, confident soldier may have learned to carry
his Dragon missile and guide it to its target easily in peacetime training. But if he
has never learned to control his own fear, he may find himself too quickly
fatigued to even carry the weight, let alone keep the missile on target for 10
seconds while under real, lethal enemy fire. He may, however, still be able to
perform simple tasks. In WWII, the following observations and conclusion were
made:
(a) In the fighting for Kwajalein Atoll, troops were halted three times by
enemy fire. Their energy was exhausted even though they suffered no
casualties and had moved fewer than two miles. In the Normandy
invasion, a strong infantry company with many vigorous young men hit
the beach still fresh. Under intense fire, they found they had to drag their
heavy machine guns across the beach a few feet at a time; when in
training, they had been able to carry the same loads on the run.
(b) The Army reached the following conclusion from those observations:
Fear and fatigue effect the body in similar ways. Fear, like physical work,
drains the body of energy. This creates a self-perpetuating cycle. The
overloaded soldier, feeling tired, becomes more susceptible to fear. The
more fearful he becomes, the weaker he feels, and the more quickly he
becomes fatigued.
2-7. Stages of Adaptation to a Threatening Situation
a. The stage of alarm (usually brief) is when the fight or flight response is extremely
active. Performance is likely to be impaired unless the soldiers' responses are simple and
instinctive (like running or freezing) or well drilled.
b. The stage of resistance is achieved if the subject successfully copes with the threat.
The overarousal moderates and the sufferer begins to actively try to overcome or escape
the stressor or to adapt to it. Performance is often enhanced in the stage of resistance. If
the stressor is mastered or adapted to, the person either returns to the baseline level of
stress or may have some residual stress while working through the unpleasant memories
and their long term implications.
c. The stages of exhaustion may occur if the victim of stress is unable to escape,
overcome, or tolerate a severe stressor. Performance deteriorates and may cease
altogether. The victim may develop a stress-related illness and can even die of stress.
Section II. COMBAT PERFORMANCE AND COMBAT STRESS
BEHAVIORS
2-8. Phases of Adaptation to Combat
During the first time in battle for soldiers, their combat performance is usually lower than it was
in precombat training. The novice soldiers are also at relatively high risk of being killed or
wounded. This is partly because they have not yet learned to identify and respond automatically
to the true dangers (such as the specific sounds of incoming artillery or mortar rounds). Under
extreme stress, they may experience difficulty with focusing their attention and remembering
what they were taught in training. Their ineffectiveness may also be caused by fearinduced
fatigue. First-battle soldiers are at high risk of becoming battle fatigue casualties. Soldiers in
their first time under fire are likely to experience high anxiety (the stages of alarm) (see Figure 22[A]). Poor showing on first exposure to real battle can be reduced by providing tough, realistic
training (especially battle drills under high stress), but it cannot be totally prevented.
a. The Experienced Veteran. If the soldier does not become a casualty in the first battle,
his combat skills will improve quickly over the next few days. His skills continue to
improve gradually over the next weeks until he is as good as he can get. An experienced
soldier gains confidence in his skill, comrades, and leaders (see Figure 2-2[B]). For him,
the stage of alarm is mostly in anticipation. He responds selectively and automatically to
the truly dangerous sounds and cues of the battlefield. When the action starts, he
immediately achieves the stage of resistance and is remarkably calm as he focuses on his
job. However, the veteran is likely to have a considerable rebound of arousal and anxiety
when the fight is over. Not all veteran soldiers ever achieve the state of really low fear in
action. Some drop to mid levels, yet still perform their duties effectively.
b. Sustainment of Optimal Combat Skills. Combat skills and high stress tolerance are
maintained when frequent successful combat actions occur. If losses in the unit remain
low, the veteran can maintain his optimal combat skills for many months. If there is a
prolonged cease-fire or if the skilled soldier leaves the combat zone on individual R&R,
there may be a brief drop in performance on his return to battle. That drop would be
accompanied by a return of the anxiety pattern shown by new soldiers (Figure 2-2[A])
but the anxiety is much briefer. This would be like the anxiety felt by the airborne
qualified soldier who is making a jump after not having done so for many months.
Predictably, the experienced veteran will regain his combat edge quickly upon returning
to battle.
c. The Overstressed Veteran. If the unit suffers many casualties, however, and the chance
of surviving a long war seems poor, the experienced soldier's combat performance begins
to decline. It can occur after 14 to 21 days of cumulative combat or even after only a few
days of extremely heavy losses. The overstressed veteran becomes more careful, loses
initiative, and may be indecisive when he needs to act quickly. Figure 2-2(C) shows the
anxiety pattern of an overstressed soldier who is doubting his chances of survival. There
were too many close calls in the last battle; too many of his friends were killed (slowly
over time or quickly). Under such stress, he feels his own skills are slipping, and it is just
a matter of time before he, too, will surely be killed or maimed. Unless he is given the
opportunity and help to reduce arousal level and regain some hope, he will soon fail.
Figure 2-2. Anxiety, fear and arousal at different stages in combat tour.
d. Decline of Combat Skills. How quickly performance declines will usually be related to
how many casualties have occurred and how close the soldier was to them (both
physically and emotionally). The decline may be hastened or slowed by leadership, unit,
scenario, and home front factors such as those discussed in later chapters and in
Appendix A.
e. Restoration of Combat Skills. Rest and recuperation, preferably with other soldiers in
the unit, can substantially restore combat proficiency. Rest would also substantially
return the anxiety pattern to that of the experienced veteran (Figure 2-2[B]). This
recuperation can be accomplished with the help of the medical and combat stress
control/mental health personnel at a medical restoration or reconditioning facility.
2-9. Combat Stress Behaviors
a. Combat Stress Behaviors. Combat stress behavior is the generic term which covers the
full range of behaviors in combat, from behaviors that are highly positive to those that are
totally negative. Table 2-2 provides a listing of positive stress responses and behaviors,
plus two types of dysfunctional combat stress behaviors-those which are labeled
misconduct stress behaviors and those which are labeled battle fatigue.
b. Positive Combat Stress Behaviors. Positive combat stress behaviors include the
heightened alertness, strength, endurance, and tolerance to discomfort which the fight or
flight stress response and the stage of resistance can produce when properly in tune.
Examples of positive combat stress behaviors include the strong personal bonding
between combat soldiers and the pride and self-identification which they develop with the
combat unit's history and mission (unit esprit). These together form unit cohesion-the
binding force that keeps soldiers together and performing the mission in spite of danger
and death. The ultimate positive combat stress behaviors are acts of extreme courage and
action involving almost unbelievable strength. They may even involve deliberate selfsacrifice. Positive combat stress behaviors can be brought forth by sound military training
(drill), wise personnel policies, and good leadership. The results are behaviors which are
rewarded with praise and perhaps with medals for individual valor and/or unit citations.
The positive combat stress behaviors are discussed further in Chapter 3.
c. Misconduct Stress Behaviors. Examples of misconduct stress behaviors are listed in the
center column of Table 2-2. These range from minor breaches of unit orders or
regulations to serious violations of the Uniform Code of Military Justice (UCMJ) and
perhaps the Law of Land Warfare. As misconduct stress behaviors, they are most likely
to occur in poorly trained, undisciplined soldiers. However, they can also be committed
by good, even heroic, soldiers under extreme combat stress. Misconduct stress behavior
can be prevented by stress control measures, but once serious misconduct has occurred, it
must be punished to prevent further erosion of discipline. Combat stress, even with heroic
combat performance, cannot justify criminal misconduct. See Chapter 4 for a discussion
of misconduct stress behaviors.
d. Battle Fatigue. Battle fatigue is also called combat stress reaction or combat fatigue.
See Table 2-2 for examples of battle fatigue. Those battle fatigue behaviors which are
listed near the top may accompany excellent combat performance and are often found in
heroes, too. These are normal, common signs of battle fatigue. Those that follow are
listed in descending order to indicate progressively more serious or warning signs.
Warning signs deserve immediate attention by the leader, medic, or buddy to prevent
potential harm to the soldier, others, or the mission. Warning signs do not necessarily
mean the soldier must be relieved of duty or evacuated if they respond quickly to helping
actions. However, soldiers may need evaluation at medical treatment facilities to rule out
other physical or mental illness. If the symptoms of battle fatigue persist and make the
soldier unable to perform duties reliably, then medical treatment facilities, such as
clearing station and specialized combat stress control teams, can provide restorative
treatment. At this point, the soldier is a battle fatigue casualty. For those cases, prompt
treatment close to the soldier's unit provides the best potential for returning the soldier to
duty. See Chapter 5 for a detailed discussion of battle fatigue.
Table 2-2. Combat Stress Behaviors
2-10. Overlapping of Combat Stress Behaviors
The distinction between positive combat stress behaviors, misconduct stress behaviors, and battle
fatigue is not always clear. Indeed, the three categories of combat stress behaviors may overlap,
as diagrammed in Figure 2-3. Soldiers with battle fatigue may show misconduct stress behaviors
and vice versa. Heroes who exemplify the positive combat stress behaviors may suffer symptoms
of battle fatigue and may even be battle fatigue casualties before or after their heroic deeds.
Excellent combat soldiers may commit misconduct stress behaviors in reaction to the stressors of
combat before, during, or after their otherwise exemplary performance. Combat stress, even with
good combat behavior, does not excuse criminal acts. However, it could be taken into account as
an extenuating circumstance for minor (noncriminal) infractions or in determining nonjudicial
punishment under Article 16, UCMJ, for minor offenses.
Figure 2-3. Overlapping of combat stress behaviors.
2-11. Post-Traumatic Stress Disorder
Post-traumatic stress symptoms are normal responses after extremely abnormal and distressing
events.
a. Post-Traumatic Stress Disorder Signs and Symptoms. As with battle fatigue, posttraumatic stress symptoms come in normal/ common and warning signs. These signs and
symptoms do not necessarily make the sufferer a casualty or deserve the label of disorder.
It is normal for the survivor of one or more horrible events to have painful memories; to
have anxiety (perhaps with jumpiness or being on guard); to feel guilt (over surviving or
for real acts of omission or commission); and to dream unpleasant dreams about it. This
becomes PTSD only when either the pain of the memories or the actions the person takes
to escape the memories (such as substance abuse, avoidance of reminders, social
estrangement, and withdrawal) interfere with occupational or personal life goals.
b. Post-Traumatic Stress Disorder Preventive Measures. As with battle fatigue, there is
no virtue in suffering, ignoring, neglecting, or hiding post-traumatic stress symptoms.
The normal/common signs deserve routine preventive measures, such as talking out and
working through the painful memories. The warning signs certainly deserve this
attention, as self-aid, buddy aid, and leader aid. Good preventive measures can head off
true PTSD which might not show up until years after the incident.
c. Relationship Between Post-Traumatic Stress Disorder and Battle Fatigue. While
PTSD and battle fatigue obviously share much in common, by definition, symptoms are
not PTSD until the trauma is over (post). Therefore, this diagnosis should not be made
while the soldier continues in, or is expected to return quickly to, the combat mission. As
the dotted lines (Table 2-2) show, PTSD can follow battle fatigue (especially if
inadequately or incorrectly treated). Israeli studies confirm earlier observations that
immediate, far-forward treatment and return to duty protect battle fatigue casualties
against subsequent PTSD. Premature evacuation of battle fatigue casualties often results
in chronic PTSD. However, most cases of acute, chronic, and delayed PTSD after a war
were not battle fatigue casualties during the battles.
d. Relationship Between Post-Traumatic Stress Disorder and Misconduct Stress
Behavior. Post-traumatic stress disorder often follows misconduct stress behaviors. It
may occur in -o
o
o
o
o
The victims of others' misconduct.
Those who committed misconduct under stress and are haunted by guilt later.
Those who were passive or reluctant participants.
Those who simply observed severe misconduct and its human consequences.
Those who were involved as rescuers or care givers.
e. Post-Traumatic Stress Disorder and Positive Combat Stress Behavior. Post-traumatic
stress disorder can also occur in soldiers (or veterans and civilians) who showed no
maladaptive stress behaviors at the time of the trauma and who showed positive, even
heroic, combat stress behaviors. Even heroes can feel delayed grief and survivor guilt for
lost buddies or be haunted by the memory of the enemy soldiers they killed in battle.
f. Leader Responsibilities to Prevent Post-Traumatic Stress Disorder. During the
conflict, commanders and NCOs have the additional responsibility of preventing or
minimizing subsequent PTSD. The most important preventive measure is routine afteraction debriefing by small teams after any difficult operation (see Chapter 6 for
additional discussion). Critical event debriefings led by trained debriefing teams should
be scheduled following exceptionally traumatic events. Recommended leader actions are
provided in Appendix A. When units or individual soldiers redeploy home from combat,
leaders should debrief them and help prepare them for the transition. As Figure 2-4
illustrates, painful memories do not have to become clinical PTSD or misconduct stress
behaviors. They can be accepted and diverted into positive growth. Chapter 6 gives more
information on PTSD and its prevention and treatment.
Figure 2-4. Relation between combat stress behaviors and PTSD.
CHAPTER 3
POSITIVE COMBAT STRESS
BEHAVIORS
3-1. Introduction
Combat and war bring out the best and the worst in human beings. The direction which a combat
stress behavior takes, positive or negative, results from the interaction of the physiological and
social context in which the stress occurs and the physiologic stress response (preparing the body
for fight or flight). The purpose of good military leadership, discipline, and training is to bring
out the best while preventing the worst.
3-2. Increased Alertness, Strength, Endurance -- Exhilaration
a. The physiological arousal caused by the stress process feels very good when it is
optimal. Soldiers describe it with words such as thrill, exhilaration, adrenaline rush, and
high. The resulting sense of focused alertness, heightened strength and endurance, and
the feeling of competence (ready for instant response) is called being on a hair-trigger or
on the razor's edge. It gives its possessors the winning edge.
b. Combat veterans may remember war and their missions in it as the most exciting, most
meaningful time in their lives -- the high peak against which later life may seem flat and
dull. Veterans returning from combat may have an experience not unlike withdrawal
from addiction to stimulant drugs -- a period of apathy and boredom, perhaps even of
depression, during which they may be inclined to deliberately indulge in dangerous
activity for the thrill of it.
3-3. Gamesmanship and Sportsmanship
a. Combat has been described as the Great Game. (Conversely, organized sports have
been called the moral substitute for war.) Many tribal or clan-based cultures have
practiced raids, ambushes, and skirmishes against other tribes for the thrill of the lethal
game, valuing the loot more as trophies and proof of valor than for its material worth.
Many fought carefully to avoid total victory because then they would have no worthy
enemies left to fight.
b. From the sense of war as an honorable sport and of the enemy as an honorable
opponent arose self-imposed rules of fair play or chivalry. These rules have slowly
become the Law of Land Warfare.
c. With organized civilization, wars intensified and were more often fought for victory
and total dominance. The sense of battle as an exciting game continues at many levels,
even in modern conflict. For many soldiers, not only stopping enemy machines but also
killing individually-targeted enemies still gives the thrill of the successful hunt.
d. With conscript armies and the increasing mechanization and depersonalization of
combat, the game metaphor may be rejected by the frontline soldiers. This rejection
occurs usually only after they have suffered bitter experiences from having tried to play
the game. The battle-hardened and weary veterans may still view combat as the great
game among themselves. These veterans resent having others who do not share the risk
see them as only players, or treat the deaths of their buddies as nothing more than a
normal part of the game.
3-4. Sense of Eliteness and Desire for Recognition
a. Sense of Eliteness. Combat veterans who have achieved a high level of combat
stimulated proficiency and self-confidence are likely to consider themselves and their
unit elite. They walk with pride and may expect special consideration or deference from
others less elite. They are likely to want to do things their way rather than by the book.
They may adopt special emblems, insignias, or TSOPs which set them apart. Up to some
degree, this eliteness is a positive combat stress behavior which enhances combat
performance. However, it is also likely to irritate others, both peers and superiors in the
chain of command. The latter recognize and adhere to the importance of uniformity and
fairness (not showing favoritism) as key factors in sustaining military discipline and
common purpose. The higher chain of command must mediate between these two
legitimate positions (eliteness and uniformity) to gain the benefits of each. This is done
with as few as possible of each position's negative side effects.
b. Desire for Recognition. Most soldiers desire public and long-lasting recognition for
their hard work, suffering, and bravery. Awards and decorations are primarily given for
this reason. Because the desire for recognition is so strong, it is important that the chain
of command be perceived as awarding recognition properly and fairly. Failure to award
recognition fairly (or failure to be perceived as awarding recognition fairly) can have
long-term consequence on morale and stress within a unit. Most soldiers accept the fact
that not all acts of heroism will be noticed. They acknowledge that receiving an
award/decoration depends not only on the heroic act but on who observed it. It also
depends on the leader to write the documentation. Commanders will differ in their policy
regarding the criteria for the different award. It is desirable to give everyone positive
motivation by making awards and decorations accessible, but if they are too easy to get,
they quickly lose their value. This devaluation creates resentment in those who most
deserve the special recognition. For this reason, higher command may set numerical
limits on how many of each type of decoration that each subordinate commander may
award. Good leaders will try to assure that exceptional performance and heroic acts get
recognized based on merit. It is important that awards be distributed across the ranks,
commensurate with performance without regards for race or gender. When it is not
possible to give everyone a medal, leaders may write letters of commendation or, as a
minimum, give a strong verbal "well done" for exceptional performance.
3-5. Sense of Purpose
War, with its stakes of life or death, victory or defeat, tends to create a sense of patriotism and
common purpose that overcomes petty complaints, jealousies, and self-interest. This is true not
only in combat soldiers but also in rear area troops. It is even true among the civilians on the
home front, provided they are emotionally mobilized and behind the war effort. They, too, may
look back on that time of common purpose and unity with nostalgia.
3-6. Increased Religious Faith
It is probably an exaggeration to say that there are "no atheists in the foxhole," but many soldiers
and civilians do find that danger, and especially the unpredictable danger of modern war,
stimulates a new or stronger need for faith in God. If this is fused with a sense of purpose in
fulfilling God's will, it may lead to living a better life, increased dedication to duty, and
attempting to make the world better in spite of the horrors and evils seen in war. In some cultures
and religions, acceptance of God's will, fatalism, faith in the afterlife, or the reward for dying in a
holy cause may also contribute to exceptional bravery and disregard for death. However, such
faith does not always promote good tactical common sense. It can lead to unproductive loss of
life unless guided by sound leadership.
3-7. Personal Bonding
While patriotism and sense of purpose will get American soldiers to the battlefield, the soldiers'
own accounts (and many systematic studies) testify that what keeps them there amid the fear of
death and mutilation is, above all else, their loyalty to their fellow soldiers. This loyalty was first
called cohesion by Ardant Du Picq (the 19th century French officer and student of men in battle).
a. Cohesion literally means stick together. The objective measure of cohesion is whether
a soldier will choose to stay with his buddies and face discomfort and danger when given
the opportunity or temptation to choose comfort and safety. The extreme measure of
cohesion is willingness to die with fellow soldiers rather than leave them to die alone, or
to choose certain death (as by throwing oneself on a hand grenade) in order to save their
lives.
b. Bonding within the combat team is itself a positive combat stress behavior. Working
together under stress to overcome difficulty and discomfort in order to accomplish a
common goal is a good way to build cohesion in a small team. Normally, such bonding
requires a long period of working together to become strong. However, the addition of
danger and potential death which can be prevented only by trust and teamwork, plus
living together 24 hours a day for days and weeks on end, forges the bond much faster
and stronger. Combat soldiers describe the bond, hesitantly or openly, as love.
c. The closest bonding naturally forms with one's buddy in combat -- the only soldier
with whom an individual ideally can share his deepest thoughts and concerns. This
bonding will also include the other close team members. Some of these may be people
whom a person might have expected (and probably did expect on first introduction) to
dislike intensely due to individual personality differences or ethnic or racial prejudices.
However, once these soldiers have proved themselves reliable, trustworthy, and
competent, they become bonded brothers in arms. Being included in the cohesion does
have to be earned by combat performance, but once established, it can lead the team to
overlook or even condone other noncombat-related faults.
3-8. Horizontal and Vertical Bonding
a. An Interlocking Framework. Horizontal bonding is the personal loyalty between peers
in the small team. This must be complemented by vertical bonding (the personal loyalty
and trust between the team's enlisted soldiers and their officer and NCO leaders). At the
next higher echelon, the junior officers and NCOs must develop strong horizontal
bonding with their peers and vertical bonding with their leaders. This hierarchical
framework of personal loyalty and trust is needed to provide the troops at the small team
level with a transmitted confidence in the units to their right, left, front and rear.
b. Cohesion, Operational Readiness Training. The Army's experimental cohesion,
operational readiness training (COHORT) program creates new combat arms companies
which keep the same soldiers together through basic training and links them with their
leaders in advanced individual training. The COHORT program then keeps the personnel
in the company or platoons together (as much as possible) through the first enlistment.
This maximizes the horizontal bonding and first level of vertical bonding. Studies have
confirmed that COHORT companies quickly reach a higher level of proficiency than
units with high turnover of personnel (turbulence). They score high on measures of
cohesion. However, they also demand much more of their leaders.
c. Cautions. Personal bonding is not enough to produce a good military unit. It is possible
to have teams which share very high personal bonding, but which are not dedicated to the
units' combat mission. In that situation, their cohesiveness may be directed solely to
keeping each other comfortable and safe. Such teams can be difficult and even dangerous
to lead. They may try to take as little risk as possible, and leaders who lead them into
danger, for example, may find themselves alone and unsupported.
3-9. Unit Identity
a. Esprit de Corps. Team cohesion must be strengthened by a sense of the unit's military
history and its mission and by a sense of shared identity which reminds soldiers of how
they should act. This sense is called esprit de corps or simply esprit.
(1) In ancient Rome this identity was formed around the numbered Legion (such
as Julius Caesar's famous Tenth) with its golden eagle standard.
(2) In the British Army, a soldier's identity is still strongly focused on the
Regiment, with the unit's hundreds of years of history, and supported usually by a
regional basis for recruiting.
(3) Since the Civil War and WWI, the US Army has discouraged regional
recruiting. The focus for our military identity has tended to be the branch (with its
insignia), special training (airborne or ranger tabs, green or red berets), the
division (with its distinctive patch), and the battalion (with its unit flag and battle
streamers).
b. New Manning System. The Army's new manning system is seeking to reinforce unit
identity by designating regiments and giving them distinctive regimental crests. The
system will encourage career progression which brings the same officers and NCOs
together again in different assignments. This will provide the personnel more time
working together in which to form horizontal and vertical bonding at all levels. It also
will increase the shared sense of tradition.
c. Summary. The patches, insignias, flags, and standards provide visual reminders of the
tradition and quick identifiers of who our fellow members are. The names or numbers
which designate the unit provide a conceptual framework for the esprit de corps to
develop around. However, the more important issue is the content of the verbal or written
tradition. For the esprit de corps to call forth positive combat stress behaviors under
stress, it must model the desired behaviors -- courage, loyalty to buddies, obedience to all
lawful orders, initiative and ingenuity, endurance even in the face of impending disaster,
and self-sacrifice. It must also uphold the code of honorable conduct of American values
and the Law of Land Warfare.
3-10. Unit Cohesion
a. Especially in small units, all soldiers come to know and appreciate their peers and
leaders. They recognize how all members of the unit depend on one another. With this
recognition comes a feeling of intimacy (personal bonding) and a strong sense of
responsibility. This mutual trust, based on personal face-to-face interaction, is called
"cohesion." Also important is esprit de corps, the feeling of identification and
membership in the larger, enduring unit with its history and ideals -- the battalion,
regiment, and division, and beyond them the branch and the US Army. Cohesion holds
units together; esprit keeps them dedicated to the mission. Personal bonding alone is like
steel wire mesh: it is extremely hard to break but easy to bend. Unit identity (or
patriotism, or other abstract ideals) is like concrete: it keeps its shape but shatters easily
under the pressure and pounding of combat. Combining the two is like reinforced
concrete: it neither bends nor breaks. It can only be chipped away chip by chip and is
extremely hard to demolish even that way.
b. Like other positive combat stress behaviors, unit cohesion is not free of potential
drawbacks. The possible liabilities resulting from an excessive sense of eliteness was
mentioned above in paragraph 3-4. Highly cohesive units may also be really slow to
accept and incorporate new replacements. When too many of the old unit members are
lost in too short a time, the unit may either fail catastrophically, lose many veterans as
battle fatigue casualties, or lose the unit esprit and become totally concerned only with
self and buddy survival. Unit leaders and the higher headquarters need to take appropriate
actions to safeguard against these possibilities.
3-11. Heroism
a. The ultimate positive combat stress behaviors are acts of heroism. The citations for
winners of the Medal of Honor or other awards for valor in battle document almost
unbelievable feats of courage, strength, and endurance. The hero has overcome the
paralysis of fear, and in some cases, has also called forth muscle strength far beyond what
he has ever used before. He may have persevered in spite of wounds which would
normally be so painful as to be disabling. Some heroes willingly sacrifice their lives
knowingly for the sake of their buddies.
b. Those who survive their own heroism often have a difficult time describing how it
happened. A few may not even remember the events clearly (have amnesia). More often
they remember selected details with remarkable clarity. They may say, "I don't know how
I did it. I remember being pinned down and scared, but I saw what needed to be done,
and something came over me. It was like it was happening to someone else" (or like I
was watching myself in a movie" or like an out-of-my-body experience").
c. In psychiatry, these experiences would be called dissociative reactions. If they resulted
in inappropriate behavior, they would be classified as dissociative disorders. Indeed,
many such cases may go unrecorded except by sad letters from the soldier's commander
to the family -- killed while performing his duties. However, when the behavior has been
directed by sound military training (drill) and strong unit cohesion, the doer receives a
well-deserved medal for heroism in order to encourage similar positive combat stress
behavior in others. Posthumous medals also console the survivors and the heroes' families
and reassure them that the memory of the hero will live on in the unit's tradition. Medals
are awarded based on the results of a soldier's actions, not for the motives that prompted
such actions or acts of bravery.
3-12. Positive and Misconduct Stress Behaviors -- The Double-Edged Sword
Positive combat stress behaviors and misconduct stress behaviors are to some extent a doubleedged sword or two sides of the same coin. The same physiological and psychological processes
that result in heroic bravery in one situation can produce criminal acts such as atrocities against
enemy prisoners and civilians in another. Stress may drag the sword down in the direction of the
misconduct edge, while sound, moral leadership and military training and discipline must direct
it upward toward the positive behaviors. (See Figure 3-1.) The following chapters will explore
this issue further.
Figure 3-1. Positive and misconduct stress behaviors -- the double-edged sword
CHAPTER 4
COMBAT MISCONDUCT STRESS
BEHAVIORS
4-1. Introduction
Misconduct stress behaviors are most likely to occur in units with poor morale or in units where
problems exist. This chapter discusses misconduct stress behaviors. It identifies factors which
could increase such behaviors and factors which help protect against such behaviors.
4-2. Indications of Potential Misconduct Stress Behaviors
Since WWI, leaders and mental health personnel have been taught to monitor for indicators of
poor morale and problems in a unit. These indicators may include increased -



Disease and nonbattle injury rates.
Disciplinary infractions.
Absent without leave (AWOL) rates.
Drug and alcohol abuse.
Often, these misconduct stress behaviors may be the result of stressors and increased stress in a
unit. These indicators could be a warning that the potential exists for heavy battle fatigue
casualties if this unit is sent to combat.
4-3. Behaviors of Primary Concern to Command and the Law of Land Warfare
Reacting to some misconduct stress behaviors is primarily the responsibility of the commanders
and the legal system. While all misconduct stress behaviors are disciplinary problems, the
extreme examples are violations of the Law of Land Warfare. Violations of the Law of Land
Warfare must be reported and the offender(s) brought to justice. While medical, psychological,
or psychiatric consultation may, in specific cases, be requested to document mental or organic
illness that might support a defense of insanity, combat stress alone is no defense for criminal
misconduct. Severe combat stress could be considered as an extenuating factor in determining
the soldier's sentence. Examples of such misconduct stress behaviors follow.
4-4. The Misconduct Stress Behavior of Opting Not to Take Prisoners
a. It has always been true (although not always admitted) that there comes a time in the
heat of battle when soldiers in combat may decide to deliberately kill the enemy rather
than take them as prisoners. The normal rage of combat stress will not accept that the
enemy soldier who has just fought to his last bullet, killed your buddy, and almost killed
you should survive to be a prisoner of war (PW), safe from the continuing danger that
you must still face. This rage of battle can reach epic proportions in otherwise excellent
soldiers. S.L.A. Marshall described two exemplary bayonet assaults in which victorious
US units took no prisoners and went on to slaughter the barnyard or pack animals -- and
were ashamed to admit it afterwards.
b. Soldiers may feel guilty about not having accepted the surrender of the enemy, just as
they often feel guilty about killing their first armed enemy at close range. Later, they may
feel guilty about not feeling guilty any more -- about how easy it has become.
c. Good leaders must work to keep the rage of battle from leading to massacre. Appeals
to higher ethical ideals and respect for the enemy as brave soldiers similar to ourselves
are useful but may be unheeded in the noise of battle. It may be more productive to
remind the soldiers (and oneself) that there are good reasons for accepting surrender of
the enemy and treating the prisoners humanely:
o
o
o
o
o
o
Not all the enemy fight to the last bullet. Many probably were there under duress,
kept their heads down, and only fired their weapons haphazardly while their
superiors were watching.
Alive, enemy prisoner(s) of war (EPW) may give valuable information to our
military intelligence personnel.
Other enemy soldiers, hearing that surrender is possible, will be less likely to fight
so desperately when confronted, thereby decreasing our casualties.
The enemy will be more likely to accept the surrender of our soldiers who may
find themselves in a hopeless position.
Killing enemy soldiers who are attempting to surrender is murder and a violation
of the Law of Land Warfare. It must be reported by any who observe it and may
result in trial by court-martial.
Soldiers who commit such acts in combat are likely to feel great guilt about it
after returning home and are often haunted by the memory for the rest of their
lives.
4-5. The Misconduct Stress Behavior of Killing Enemy Prisoners
a. The ambiguous case of not recognizing attempts to surrender during a hot assault can
be distinguished from killing soldiers who surrender after no (or only token) resistance.
There is no excuse for killing prisoners after they surrender unless they are resisting or
attempting to escape. Although the same urge for revenge may still be understandable, if
prisoners are killed without cause, it is undoubtedly murder. Killing of prisoners must be
actively prevented by command as a serious violation of the Law of Land Warfare.
Violators are subject to trial and punishment.
b. It is also understandable but an unacceptable stress reaction for stressed commanders
to overlook such incidents when done by otherwise good soldiers whom they need as
fighters. Overlooking these incidents and failing to take action to prevent them is itself a
violation of the Law of Land Warfare and may subject such commanders to trial by
court-martial.
NOTE
All personnel, including health care providers and combat stress control/ mental health
personnel, must be alert for signs of misconduct stress behaviors. They must advise the
commander. Chaplains also should be alert and inform command about trends or
stories/rumors of misconduct stress behavior. They, however, must maintain an
individual soldier's confidentiality if told in the course of their religious duties.
4-6. The Misconduct Stress Behavior of Mutilating Enemy Dead
a. This practice has been prohibited by civilized nations as a violation of the Law of Land
Warfare but may still be approved in some regions of the world. Collecting scalps, ears,
gold teeth, and so forth as trophies can still become common practice (as in the island
battles of the Pacific in WWII)as signs of racial hatred and dehumanization against a
stubborn and merciless enemy.
b. Leaving deliberately mutilated bodies (especially with facial and genital mutilation) for
the enemy to find is less common, but also occurs as bitterness increases. Despoiling or
pillaging the dead is, of course, a war crime and is punishable by court-martial.
NOTE
Mutilating the dead must be prohibited, since it dehumanizes both those who do it and
those who condone it. It tends to provoke reprisals, alienate world and home front
opinion, and contribute to guilt and post-traumatic stress symptoms when the soldier
returns home.
4-7. The Misconduct Stress Behaviors of Torturing Prisoners, Using Excessive Force or
Brutality, and Killing Animals
a. In some cultures or religions (such as many of the seventeenth/eighteenth century
North American Indian tribes), torture has been accepted by all parties as the proper thing
to do. The captive warrior who died bravely under torture was highly respected. Under
the Law of Land Warfare, torture is a war crime and is forbidden but is still sometimes
practiced. It may be erroneously justified as necessary to gain information to assure
victory and save friendly lives or to intimidate the opposition, especially in
counterinsurgency scenarios.
NOTE
If torture to gain information or to intimidate is allowed, even tacitly, it can become an
all-too-easy outlet for combat stress-related tension and frustration, with steadily
worsening consequences.
b. The more insidious and common form of this misconduct stress behavior is to react
with excessive force or brutality to episodes of provocation. The boundary between
excessive and prudent is a gray area. It is related to the magnitude of the enemy
provocation and the likelihood of its continuing if not answered. Examples of
overreaction include reacting to a single sniper or mortar fire from a civilian housing area
with massive artillery and air attack, or going in to beat all the villagers and destroy all
the houses.
c. It is difficult and frustrating for soldiers to adhere to strict rules of engagement, such as
never firing into civilian areas until fired on and only returning fire with precision when
the specific enemy has been located. It is especially difficult if the enemy is deliberately
using such areas as sanctuaries and the civilians are tacitly or even explicitly siding with
the enemy. Such self-control is, however, often essential to accomplish the national
objectives in military operations other than war. To maintain fire discipline, leaders must
instill and continually reinforce a sense of strong unit identity and cohesion that actively
encourages and rewards correct behavior.
d. Stress-induced behaviors that impair fire discipline can also cause friendly fire
casualties. In some cases, overeagerness to attack the enemy (perhaps resulting from the
positive combat stress behaviors of desire for glory, medals, or promotion) may lead to
tragic error. Too much arousal or anxiety may cause soldiers who are "on a hair trigger"
to misidentify vehicles, to make errors in reading maps or grid coordinates, or to shoot
first and ask questions later. There is a well-documented tendency for hypervigilant
persons to misinterpret and even to misperceive stimuli in ways which seem to confirm
their preconceived fears.
(1) Consider the pressure on the tank crew which is constantly remembering that
in an engagement between two equal opponents the tank that fires second has
only one chance out of five of surviving. Add to that many hours of continuous
operations and rapid movement with little sleep. Now add that beyond the unit's
right boundary is an unknown friendly unit. This unit may be from a different
division, corps, service, or allied nation. The tank unit's leader and higher
headquarters must recognize that these tank crews are at high risk of violating the
TSOP and firing across the boundary into the neighboring area.
(2) In such situations, the unit leaders (even tired, anxious leaders) must perform a
recurring process of risk analysis and risk management. Friendly fire casualties
cannot rationally be completely prevented in modern, fast-moving battles.
Commanders and leaders must implement policies and prudent precautions which
will minimize friendly fire casualties while also minimizing the risk of the enemy
killing our soldiers.
(3) The targeting policy which maximizes the odds of hitting the enemy first may
be entirely justified at the beginning of the battle. Then, the enemy's strength is
uncertain and his crews and tanks must be assumed approximately equal in
quality to our own. Later in the battle, a more cautious policy may be justified. It
may be clearer that most (if not all) of the enemy are undertrained, out-gunned,
and badly overstressed. Our own crews, though still aggressive, are becoming
fatigued as a result of the battle or because of sleep loss. Their alertness,
coordination, and senses may be dull.
(4) The leaders must recognize these stress factors. They must implement
precautions to ensure that there are no friendly fire casualties. They must consider
modifying or changing the targeting policy if stress factors are high. They must
then assure that the change, its reasons, and any related coordinating instructions
are passed down the chain of command to every crew. Recent experience is that
leaders will be held publicly accountable if they fail to do this and friendly deaths
result. This is true even though the leaders' misconduct may be a reaction only to
their own combat stress.
e. Other examples of excessive force or brutality involve the killing of animals.
(1) Soldiers may deliberately shoot domestic animal(s) of local farmers as acts of
hatred or revenge. Soldiers may later claim that the animal(s)' death was an
accident. Leaders should investigate and ensure appropriate actions are
implemented to prevent future incidents of this nature. All soldiers must
understand that the senseless killing of animals is a punishable crime under the
UCMJ.
(2) Warning signs of excessive stress may be indicated when individual soldiers
begin to mistreat, torture, and kill animals. These types of behaviors are warning
signs to commanders and leaders that self-control among some of their soldiers is
wearing thin. Unit cohesion may also suffer, since other members of the unit may
feel revulsion and anger at such behaviors. Leadership must recognize such signs
of stress and take actions to provide less destructive ways of relieving the tension
and frustration.
4-8. The Misconduct Stress Behaviors of Looting, Pillage, and Rape
a. All these behaviors (looting, pillage, and rape) may be misconduct stress behaviors,
although they may also be committed by soldiers with antisocial norms or personality
traits and no combat exposure. They may reflect aberrant group norms in soldiers who
have experienced little combat stress. Less than 180 years ago, it was the accepted
custom that besieged cities which did not surrender before their wall was breached and
which therefore had to be taken by assault, were always turned over to the troops to loot
and rape. This is no longer acceptable and is a violation of the Law of Land Warfare.
However, the stressed combat veteran may still feel entitled to collect souvenirs and
perhaps to loot, pillage, and even rape the hostile (or even friendly) noncombatants. He
may feel he has earned the right by his suffering, risks, and losses.
b. Rape is sometimes used as a symbolic act of dominance, not only over female victims,
but also over males in her social system who are powerless to prevent it. Rape forcibly
degrades and humiliates the victim and everyone in his or her group, which naturally
provokes resentment and reprisal.
NOTE
Only a strong chain of command and a unit identity which says, "We don't do that and
those who do aren't one of us and will be punished" can keep looting and rape from
happening.
c. The distinction between looting and raping local nationals versus voluntary donation
and social interactions is not always clear when only the soldiers have weapons. Sexual
exploitation of local women by soldiers may foster local resentment and detract from the
mission, even when paid for with food, cigarettes, money, or luxury items. Leaders,
combat stress control/mental health personnel, and chaplains need to be alert to these
facts to prevent abuse. It is the commander's responsibility to set and demand high
standards as the ethical role model for the unit.
4-9. The Misconduct Stress Behavior of Fraternization
a. Incidents of fraternization, sexual favoritism or harassment, prostitution, and even rape
may occur within US Army units. The stress of combat, the reminders of the nearness of
death, prolonged separation from home, boredom, and other stressors bring out the
natural human tendencies to form relationships -- or to exercise aggressive impulses and
personal dominance.
(1) Sexual misconduct stress behaviors within units can be destructive to unit
cohesion and morale. That is especially true when leader-subordinate or officerenlisted relationships are (or are misperceived to be) directly involved. Even
misconduct stress behaviors involving mutually consenting peers can seriously
disrupt unit functioning. This can also hamper individual and family readjustment
after the return home.
(2) All unit members, as well as unit leaders and staff members of higher
commands, have the personal responsibility to maintain a professional and social
climate which prevents the misconduct of fraternization from getting started.
Everyone should actively discourage (rather than tacitly condone or assist) mixedgender couples from pairing off except when required by the mission. At the same
time, there should be ample opportunity for larger group, mixed gender social
activities and morale support.
b. Leadership must set the example and must enforce the UCMJ regulations against
fraternization, harassment, adultery, and criminal assault. The enforcement policy must
be made unquestionably clear to all unit members in advance. Punishment for violating
the fraternization policy must be evenly and strictly executed.
4-10. The Misconduct Stress Behavior of Killing Noncombatants
a. Some incidents of mass execution of civilians (for example, those committed by Nazi
Germany) are acts of deliberate policy and are outside the scope of this discussion.
Others, like the My Lai massacre in Vietnam, although premeditated, are clearly
reactions to cumulative combat stress. These misconduct stress behaviors are likely,
especially in guerrilla warfare, when some seemingly noncombatants, such as women and
children, are in fact ununiformed combatants. Misconduct stress behavior is also likely
when the sympathies of the civilian noncombatants have become suspect as they allow
the soldiers' buddies to be killed and mutilated by mines and booby traps which they
themselves avoid.
b. Other examples of killing civilians may be impulsive, individual stress reactions or
rage attacks: One soldier who has just seen his buddy killed impulsively shoots two
children on a water buffalo. The hot, angry, frustrated soldier shoots the peasant who is
shouting at him in a foreign language about trampling her vegetable garden. The fact is
that overstressed human beings with loaded weapons are inherently dangerous.
NOTE
Commission of murder and other atrocities against noncombatants must be reported as a
war crime and punished if responsibility is established. This must be done even though
we may pity the overstressed soldier as well as the victims.
4-11. The Misconduct Stress Behavior of Fighting with Allies or United States Forces
a. Fighting is, of course, what soldiers are trained to do, but they are supposed to direct
that skill and energy against the enemy. However, highly cohesive groups, where they
believe they are the best, naturally make derogatory remarks about each other. Honor
may then require that the insult be resolved by fighting. As long as the fighting is fair and
forbids dangerous weapons and crippling techniques, it may actually help sustain
cohesion and fighting spirit while promoting grudgingly mutual respect. Such fights
between members of different units with rival traditions, different services, or allied
forces have sometimes been tacitly or even explicitly condoned by their leaders. A better
solution is to initiate a competitive sports program among the rivals which allows them to
test each other's strength and courage with less risk of serious injury.
b. Fighting against allies and other US forces becomes a more dangerous stress behavior
when it is the result of -o
o
o
o
o
o
Alcohol abuse.
Stress of impending or past battle.
Battle-generated mistrust.
Cultural differences.
Racial prejudice.
Ethnic prejudice.
It clearly becomes misconduct when the rules of fairness are stretched so that seriously
harmful tactics, techniques, and weapons are used. The result is then injury or death.
Persistent bad feelings may result that interfere with cooperation between units, services,
and allies.
c. This misconduct stress behavior is most common in the period of tension before
deployment to battle, or of persistent tension during prolonged lulls or withdrawal of
units from combat. Most soldiers who are in battle against the real enemy (or on brief
R&R) are not looking for these "intramural" fights. However, some rear area support
troops may be, to try to enhance their macho image. That can irritate the combat troops
until serious fights result.
NOTE
Leaders and combat stress control/ mental health personnel must be alert and sensitive to
signs that stress is driving high spirits and unit pride across the very fine line from
occasional friendly intramural fighting to misconduct stress behaviors.
d. It is obviously serious when fights break out between groups who have been traditional
allies in such brawls, or within a previously cohesive unit. It is also traditionally more
serious (and usually subject to serious UCMJ disciplinary action) when a soldier strikes a
superior officer or an NCO. This, too, can clearly be due to combat or other stress, which
might be taken into consideration in deciding punishment.
4-12. The Misconduct Stress Behavior of Being Absent Without Leave or Deserting
Going AWOL or deserting may be misconduct stress behaviors, but are punishable under the
UCMJ unless there exists some legal justification or excuse. Possible defenses to a charge of
AWOL or desertion include insanity or amnesia with the (rare) trance type of battle fatigue. In
the Western democracies, less use of capital punishment for civilian crimes has also reduced the
frequency of firing-squad executions of deserters "to discourage the others." Nevertheless, the
death penalty is still allowed under the UCMJ for deserting in time of war.
4-13. The Misconduct Stress Behavior of Refusing to Obey an Order
a. A soldier deliberately refusing to obey an order in combat, as a misconduct stress
behavior, may be tactically inappropriate (based on an unduly narrow, self-interested, or
pessimistic perception of the situation). Alternatively, it may be tactically appropriate
(based on a realistic perception that the order is unwise and will get one killed for no
purpose). However, all orders which do not involve explicit violation of the Law of Land
Warfare are presumed to be lawful and must be obeyed. The dictates of a person's
conscience, religion, or personal philosophy (let alone fear or misgivings) cannot legally
justify or excuse the disobedience of a lawful order. Combat refusal by units has
historically been dealt with by measures as extreme as summary execution of ringleaders
or decimation (the arbitrary execution of every tenth soldier). The UCMJ currently
provides a maximum punishment of death for this offense when it is committed before
the enemy.
b. Army operations expects leaders to keep troops informed of the "Big Picture" and the
commanders' intent. Good leaders may give their subordinates more opportunity to
express their concerns about an order which they consider unwise and to suggest
alternatives to accomplish the objective. Once ordered, however, combat refusal of lawful
orders will still be punishable. The alternatives to unwise yet lawful orders will continue
to be -o
o
o
o
An. appeal to higher headquarters through the chain of command, chain of
support, or special staff (perhaps with a dramatic demonstration of good faith,
such as requesting to be relieved of responsibility or command while continuing
in the mission as a common soldier).
Vigorous compliance to the lawful order (it is worth remembering that the famous
Charge of the Light Brigade in the Crimean War was successful, although costly
and pointless except for the glory it won).
Cautious and skillful compliance while hoping for a reappraisal and reprieve.
Unacceptable solutions, such as one of the other negative combat stress behaviors,
including involuntary disability through battle fatigue.
c. Less extreme forms of this type of misconduct stress behaviors would be refusing,
ignoring, shirking, or otherwise avoiding orders which do not involve the combat
mission. The orders may be obeyed but with obvious signs of disrespect to the superior
officer or NCO. Persistent breaches of military courtesies, uniform regulations, and other
general orders or TSOPs may also be misconduct stress behaviors and are sometimes
seen in otherwise effective combat veterans.
d. The distinction between misconduct stress behavior and battle fatigue can be blurred in
reality. If an act of insubordination is clearly a misconduct stress behavior and the tactical
situation allows, the leader may elect to handle it by telling everyone, "Oh, he's just got
battle fatigue" and treating it with reassurance, brief rest, physical replenishment, and
activities to restore confidence. In a situation that requires stronger disciplinary action,
such as insolence or assault on a superior, the soldier may be charged with
insubordination or combat refusal even though it is a misconduct stress behavior.
4-14. The Misconduct Stress Behavior of Threatening to Kill or Killing Unit Leaders or
Other Soldiers
a. Threatening to kill or killing unpopular leaders or soldiers (called "fragging" and so
named from the technique of rolling a fragmentation grenade into the victim's bunker) is
also a criminal act and subjects the offender to disciplinary action. To the extent that this
behavior is related to combat stress (rather than to some other grudge), it may involve an
individual or group perception that the victim is -o
o
o
Excessively eager to commit the unit to danger.
Grossly incompetent.
Unfair in sharing of the risks.
b. Other cases may be unpremeditated flashes of rage provoked by intense stress and the
loss of usual inhibitions against violence through combat experience. For example, a
special operations forces medic had just brought his dead teammate from an ambush to a
supporting hospital. When a mortuary affairs specialist casually flicked cigarette ashes
onto his dead buddy's face, the medic drew his knife with every intention of cutting the
clerk's head off. Fortunately for both soldiers, bystanders intervened before the clerk was
seriously hurt. Fortunately for the medic, his own chain of command understood his
misconduct stress behavior. They convinced the hospital commander that it was not in
anyone's best interest to press charges.
4-15. Misconduct Stress Behaviors of Special Concern to the Medical System (Along with
Command)
Some soldiers exhibiting misconduct stress behaviors attempt to use the medical evacuation and
treatment system to escape their stressful duty. Other soldiers displaying misconduct stress
behaviors require medical or surgical treatment for the consequences of their misbehavior.
Medical personnel and administrators must recognize these cases and report them to the chain of
command. The chain of command may take disciplinary action and act to prevent future cases.
These misconduct stress behaviors of special concern are discussed in the following paragraphs.
4-16. Malingerers
a. Malingerers are those few soldiers who, in an effort to avoid duty, deliberately and
willfully fake illness, physical disablement, mental lapse, or derangement, including
battle fatigue. They must be counseled and returned to their units, even if they are
suffering from combat stress. Malingering is an offense under the UCMJ (Article 115).
The issue is not the presence of stress but whether the symptoms are under voluntary
control. The most reliable test is whether the symptoms go away when the soldier does
not think he is being watched and return when he thinks he is. Usually the malingerer
cannot fake perfectly the physical and mental indications of true physical or psychiatric
disorders.
b. The problem is how to distinguish malingering from the physical dysfunction, memory
loss, and excessive pain and disability forms of battle fatigue (see Chapter 5). Unlike
malingering, these are involuntary, but they also may fluctuate over time and with level
of attention. They seldom mimic true physical or psychiatric disorders faithfully. It has
been observed that the malingerer is likely to resent, avoid, or try to fake diagnostic tests
such as hypnosis and truth serum (sodium amytal) interviews. True battle fatigue cases
usually cooperate willingly. However, as true battle fatigue cases recover from the
psychologically caused loss of physical function, they may go through a phase of feeling
that it is now under voluntary control and, feeling guilty, may mistakenly believe (and
confess) that they were malingering all along.
c. The boundary between malingering as a misconduct stress behavior and battle fatigue
can be another gray area when both may be present in the same soldier. If all that is
needed to correct the apparent deliberate faking and turn the highly stressed malingerer
back into a good soldier is a day or two of relatively light duty, physical replenishment,
and encouragement, the leader or treater may elect to call it battle fatigue, treat the battle
fatigue, and not press charges unless the soldier continues to malinger.
d. Another form of malingering is making suicide threats and gestures (nonlethal
attempts) for the purpose of escaping unwanted duty. Here, the problem is to distinguish
malingering from true depression or impaired impulse control due to stress or battle
fatigue where the risk of death on a further suicide attempt is very real. Treating the
threat or gesture as a cry for help and assisting the soldier in coping with the stressors
without seeding trim home may separate the malingerer from the true sufferer.
4-17. Self-Inflicted Wounds
a. Self-inflicted injuries must be investigated. If deliberate, they are a form of
malingering under UCMJ (Article 115). Such injuries may require disciplinary action as
well as surgical treatment. Typical examples are shooting or stabbing oneself in the foot
or nondominant hand. More ingenious is throwing a hand grenade through a door and
holding one's arm out in hopes of being hit by a fragment. In WWI, some soldiers
deliberately exposed a patch of skin in mustard-contaminated areas. Good and even
excellent soldiers have said that the temptation to give oneself a "million-dollar wound"
becomes hard to set aside as the combat stress level increases. Some soldiers yield to the
temptation. Occasionally, buddies even collaborate to give each other wounds and alibis.
Fatigue, inattention, and carelessness make unintentional self-inflicted wounds more
likely.
b. Preventable DNBI may be the consequences of the inattention and indifference to
hygiene and self-care. Inattention and indifference are common signs of battle fatigue.
The results of stress-induced negligence may include dehydration, diarrhea, dysentery,
malaria, blisters, and cold injury. Also, stress-induced carelessness can cause mashed
fingers, sprained ankles, and more serious bodily injuries. Such disabling conditions may
be a deliberate form of malingering; however, this is often difficult to prove. Sex with
promiscuous partners and prostitutes may result in sexually transmitted diseases (STD).
With the spread of acquired immunodeficiency syndrome (AIDS), STD can once again
result in a soldier's slow death from a nonbattle cause. All DNBI must be treated and, if
necessary, evacuated, but command must be advised to redouble self-aid, buddy aid, and
preventive medicine measures. If these actions are not done, a few negligent cases can
quickly grow into an epidemic or an evacuation syndrome. Examples include gonorrhea
(WWII Italian theater), frostbite (Korea), and malaria (Vietnam).
c. Other equally important considerations are wounds or death due to failure to take cover
or other obvious precautions. While this is not deliberate misconduct, there are many
anecdotes of combat-experienced soldiers who reach a stage where they appear to be
functioning well but are so task-oriented or so fatalistic that they become easy,
unnecessary victims. Many such cases involved leaders who failed to take cover in the
presence of known snipers. Some survived to require surgical care. Many did not. It
seems that the psychological defense mechanisms of the resistance stage of stress have
betrayed, rather than protected, them. In other cases, inattention due to fatigue played an
important role. In a few cases where other background data are available, unconscious or
deliberate suicidal intent may be suspected.
4-18. Drug and Alcohol Abuse
a. Substance abuse is classified as a neuropsychiatric disorder, but may also be
misconduct stress behavior. It may represent self-medication for the anxiety and
traumatic memories of combat or for the boredom and frustrations of rear area duties.
Substance abuse may give group users an extended family and an inappropriate sense of
belonging to a special group who is "superior" to (but persecuted by) outsiders or
authority. This may be an unfortunate by-product of cohesion-producing group dynamics.
b. The following are some of the problems related to substance abuse:
o
o
o
o
o
Intoxication or withdrawal (from alcohol, barbiturates, tranquilizers, narcotics,
stimulants, and hallucinogenic drugs) may require hospitalization for
medical/neuropsychiatric stabilization.
Overuse of amphetamine-type stimulants (as deliberate abuse or by well
intentioned soldiers and leaders trying to stay alert) may cause panic attacks,
manic hyperactivity, rage attacks, and paranoid psychosis. Discontinuing
amphetamines causes a "crash" with possible serious depression and suicidal
thinking.
Abuse of anabolic steroids for body-building has been associated with mood
swings and violent attack episodes ("roid rage").
Hallucinogenic drugs cause bizarre sensory distortion, poor judgment, and
occasionally, panic and dangerous behavior. Fumes (inhaled accidentally or as
deliberate abuse) from gasoline, solvents, and spray can propellants can cause
disoriented, crazy, and violent behavior.
Atropine, the antidote for nerve agents, can cause severe heat stress, as well as
vision and cognitive problems, even at low doses. Higher doses may produce
disoriented, crazy behavior if administered when no nerve agent is present. This is
especially true in sleep-deprived or otherwise physiologically overstressed
soldiers.
c. Substance dependency and addiction require rehabilitation or administrative
disposition. Some substance abusers have good potential for return to duty, especially if
the use is stress-related. It is important not to reward substance abuse with medical
evacuation to CONUS unless there are other medical or surgical complications which
require it. Detoxication should be accomplished in the theater (combat zone or COMMZ)
and the soldier returned to duty for administrative action.
4-19. Factors Which Increase Misconduct Stress Behavior
The following factors may increase misconduct stress behavior:
a. Permissive attitude and availability and use of drugs in the region by civilians,
especially around posts or garrison areas.
b. Inadequate enforcement of the unit's Alcohol and Drug Abuse Prevention and Control
Program before deployment; failing to identify and treat (or discharge) misusers. This is a
critical issue for Reserve Component as well as Active Component units.
c. Availability and distribution networks (both legal and illegal) for alcohol and different
types of drugs in the theater. Some drugs are much more available at lower prices in
some foreign countries or regions.
d. Unsupervised and unwise use of amphetamines and other strong stimulants to remain
awake in CONOPS. This can produce dangerous (usually temporary) neuropsychiatric
illness. Also, it may lead to dependency and addiction in originally well-intentioned,
good soldiers, including leaders.
e. Boredom and monotonous duties, especially if combined with chronic frustration and
tension.
f. False alarms of nerve agent presence resulting in self-administration of atropine.
Atropine can cause problems with vision, cognitive skills, and performance if taken when
a nerve agent is not present.
g. Victorious pursuit of a retreating enemy. This reduces battle fatigue casualties but may
not inhibit commission of criminal acts (killing of EPW, rape, looting) or alcohol/drug
misuse unless command retains tight moral control.
h. Hasty withdrawal. Here, few battle fatigue casualties enter medical channels, although
battle fatigue soldiers may be lost as KIA, missing in action (MIA), or captured instead of
becoming medical patients. Other stressed soldiers may willfully desert or surrender.
Looting can occur, "justified" by the rationalization that the property would just be seized
by the enemy. Rape, murder, and other criminal actions taken as reprisal can be triggered
by stress if the retreating troops feel hindered by EPW or if the civilians being left behind
were not friendly. Leaders must take care not to lose control of the withdrawal or be too
zealous in encouraging a "scorched earth" policy.
i. Beleaguered unit which cannot evacuate any (or only the most severely wounded)
casualties. Here, too, few soldiers are identified as battle fatigue casualties although some
may become ineffective due to the severe stress. Other soldiers may go AWOL.
j. Rapid return of soldiers to close contact with noncombatant military, civilians, or
families after an intense battle experience without a unit stand-down period in which to
defuse.
k. Commission of atrocities by the enemy, especially if against US personnel, but also if
against local civilians.
l. Racial and ethnic tension which can occur within the US civilian population and among
Army personnel. Tension and misconduct may also stem from major cultural and
physical/ racial differences between US soldiers and the local population.
m. Local civilian population may be perceived as hostile, untrustworthy, or "subhuman."
This is more likely to happen if there is a lack of education and understanding of cultural
differences. Exploitation of cultural differences through propaganda to create disharmony
and mistrust may be an objective of the enemy.
n. Failure of expected support, such as reinforcement or relief; inadequate resupply;
inadequate medical support and evacuation. Soldiers who feel abandoned and on their
own may resort to illegal measures to get what they think they need. Combat soldiers
naturally tend to feel "entitled" to claim what they have "earned," and this may lead to
looting and worse.
o. High personnel turbulence, lack of unit cohesion, especially of vertical bonding
between leaders and troops. "Substance-of-choice" can become a "ticket" for inclusion
into a group.
p. Loss of confidence in leaders, in supporting or allied units, and in equipment as
compared to the enemy's. These also can lead soldiers to a sense of abandonment,
desperation, and the "right" to take shortcuts to get what they need and deserve.
q. Popular opposition at home to the war; lack of understanding or belief in the justness
of the effort. Some soldiers may find this an excuse to desert or refuse lawful orders.
Others who continue to do their duty may show their resentment by lashing out at the
local population or by using drugs and alcohol.
r. Lack of a believable plan for protecting families in the theater, either by evacuating
them or keeping them secure under reliable authority. Some soldiers may go AWOL to
stay with them or attempt to take them to safety.
4-20. Factors Which Protect Against Misconduct Stress Behavior
a. The following factors protect against misconduct stress behaviors:
o
o
High unit cohesion -- represents the commitment of soldiers of all ranks to each
other and the strength of their willingness to fight and sacrifice personal safety. It
is a product of bonding of soldiers with each other and the bonding between
leaders and subordinates. Cohesion requires strong bonds of mutual respect, trust,
confidence, and understanding within units. Cohesive units function smoothly and
perform well under stress. In organizations with high cohesion, the unit identity
forbids abuse of substances and emphasizes adherence to the Law of Land
Warfare.
Tough, realistic training -- provides the training, including faithful adherence to
rules of engagement, which support the Law of Land Warfare and addresses
o
o
o
o
o
cultural issues. Tough and realistic training is designed to develop and challenge
each soldier and unit. Tough training occurs when leaders and soldiers mutually
experience realistic exhausting conditions that prepare both, as a team, for the
stress of combat.
Unit leaders, medical personnel, and chaplains are trained -- to recognize battle
fatigue and early warning signs of misconduct stress behaviors.
Units are withdrawn from combat periodically -- to rest, refit (reconstitute if
necessary), and absorb new replacements who arrive and are integrated as
cohesive teams, not individuals.
Leaders demonstrate competence, courage, candor, and commitment. Leaders
show caring for the soldiers and make provisions for their physical, mental, and
spiritual well-being as the tactical situation permits.
Leaders keep troops informed -- of the objectives of the operations and war
(including psychological operations and diplomatic, political, and moral
objectives). They focus the soldiers' appraisal of the situation to maintain positive
coping against the temptations to misconduct stress behaviors. The commander
should utilize his public affairs officer and the public affairs assistance available
to him in an effort to keep soldiers informed.
Leaders conduct after-action debriefings -- which defuse resentments and tension
prior to soldiers coming in close contact with noncombatants (military, allied,
civilian, or family). This is most important for soldiers who return from special
operations, direct action, special reconnaissance, or counterterrorism missions.
b. The situations listed above can be extremely beneficial for leaders and troops in
maintaining and enforcing a unit self-image that regards misconduct behaviors as
unacceptable. If that view is lacking, these same situations may even contribute to
substance abuse and violations of the laws of war.
CHAPTER 5
BATTLE FATIGUE
5-1. Introduction
Battle fatigue is the approved US Army term (AR 40-216) for combat stress symptoms and
reactions which -


Feel unpleasant.
Interfere with mission performance.
Are best treated with reassurance, rest, replenishment of physical needs, and activities
which restore confidence.
a. Battle fatigue can also be present in soldiers who have been physically wounded or
who have nonbattle injuries or diseases caused by stressors in the combat area. It may be
necessary to treat both the battle fatigue and the other problems.
b. Battle fatigue may coexist with misconduct stress behaviors. However, battle fatigue
itself, by definition, does not warrant legal or disciplinary action.
c. Several of our allies use other terms for battle fatigue such as combat reaction, combat
stress reaction, or battle shock.
5-2. Contributing Factors Which Cause Battle Fatigue
There are four major contributing factors which cause battle fatigue. They are -



Sudden exposure.
Cumulative exposure.
Physical stressors and stress symptoms.
Home front and other existing problems.
Any one factor may suffice if intense enough. Usually two, three, or all four factors can
collectively produce battle fatigue.
a. The first factor is the sudden exposure or transition to the intense fear, shocking
stimuli, and life-and-death consequences of battle. This occurs most commonly when
soldiers are committed to battle the first time but can happen even to veteran soldiers
when they come under sudden, intense attack. Soldiers in "safe" rear areas may be
overwhelmed by the horrible stimuli and consequences of war without themselves being
under fire. This is an occupational hazard for rearward command and support personnel,
including medical.
b. The second factor is the cumulative exposure to dangers, responsibilities, and horrible
consequences. Exposure can cause repeated grief and guilt over loss of fellow soldiers. It
can also give the sense that one's own luck, skill, and courage have been used up. The
rate of accumulation depends on the rate of losses (KIA, WIA, died of wounds [DOW],
and other causes) and of "close calls" with disaster and death (including being wounded
oneself). Periods of rest, recreation, and retraining in which new supportive, cohesive
bonds are formed may temporarily reverse the accumulation but not stop it completely.
c. The third factor is the physical stressors and stress symptoms which reduce coping
ability. Sleep loss and dehydration are especially strong contributors. Also important are
physical overwork, cold, heat, wetness, noise, vibration, blast, fumes, lack of oxygen,
chronic discomfort, poor hygiene, disrupted nutrition, low-grade fevers, infections, and
other environmental illnesses. These stressors are also in the area of responsibility of
preventive medicine. In moderate amounts, such physical stressors contribute to battle
fatigue but are reversed by rest and time for restoration. In higher doses, they cause
serious illness or injury requiring specific medical or surgical treatment. When the major
contributing factors to battle fatigue are physical stresses that can be reversed, treatment
is usually simple and recovery is rapid. However, physical factors are not necessarily the
cause of battle fatigue. When the soldier is diagnosed, the absence of obvious physical
stressors should not detract from the positive expectation of rapid and full recovery.
d. The fourth factor is the home front and preexisting problems.
(1) Israeli studies found that the strongest factor which distinguished between
soldiers who were decorated for heroic acts and those who became battle shock
casualties was having had many recent changes on the home front. The negative
home front problem may be a "Dear John" letter, a sick parent or child, or bad
debts. Or it may be something positive -- being recently married or becoming a
parent. Worrying about what is happening back home distracts soldiers from
focusing their psychological defenses on the combat stressors. It creates internal
conflict between performing their combat duty and perhaps resolving the home
front problems or concerns.
(2) The second strongest factor found in the Israeli studies was unit cohesion: the
soldiers who became stress casualties were often committed to battle alongside
strangers, while those who became heroes were alongside unit members they
knew well, trusted, and depended on. These findings confirm observations from
previous wars. Other baseline stressors which are often cited include lack of
information; lack of confidence in leaders, supporting units, or equipment in
comparison with the enemy's; and lack of belief in the justness of the war (which
may reflect lack of support for the effort in the US).
(3) It is worth noting that individual personality makeup does not predict
susceptibility to battle fatigue. Careful studies by the US Army after WWII and
by the Israelis since the Yom Kippur War all show that there is no clear
relationship between neurotic traits or personality disorders and battle fatigue.
People with these traits were no more likely to become battle fatigue casualties
and no less likely to be decorated for valor than were those soldiers who tested as
normal.
(4) There are personality factors which may predict who will be poor soldiers (or
who may be prone to commit acts of misconduct if given opportunities or excuses
to) but not who will get battle fatigue. There are good predictors of battle fatigue
but individual personality type is not one of them. Anyone may become a battle
fatigue casualty if too many high-risk factors occur. However, personality factors
may help predict who is less likely to recover quickly after being disabled by
battle fatigue.
e. There are two common themes which interact in varying combinations in most battle
fatigue casualties -- loss of confidence and internal conflict of motives.
(1) Battle-fatigued soldiers have often lost confidence in -



Themselves -- their own strength, alertness, and abilities, or the adequacy
of their training.
Equipment -- their weapons and the supporting arms.
Buddies -- other members of the small unit, or in the reliability of
supporting units.
Leaders, to include - The skill and competence of the small unit leader or the senior
leadership.
 Whether the leaders care about the soldiers' well-being and
survival.
 The leader's candor (honesty) or courage.
These doubts, plus the soldiers' estimate of the threat situation, raise questions
about their chances of surviving and/or of succeeding with the mission. Loss of
faith in whether the "cause" is worth suffering and dying for also plays a role. It
has been said that soldiers join the military services for patriotism, but they fight
and die for their buddies and trusted leaders. Soldiers do not want their comrades
or themselves to die for an unjust cause or for other's mistakes. Loss of faith may
even spread to a painful loss of belief in the goodness of life and other spiritual
and religious values.
(2) Combat, by its nature, creates conflicts between motives within an individual.
The desire for survival and comfort is in conflict with the fears of failure or
disgrace and the soldier's loyalty to buddies. Leaders' actions must -

Raise the soldiers' confidence.
Help resolve the soldiers' internal conflict in favor of his sense of duty.
5-3. Signs/Symptoms of Battle Fatigue
a. Simple Fatigue. The simple fatigue or exhaustion form of battle fatigue is normally the
most common. It involves tiredness, loss of initiative, indecisiveness, inattention, and,
when extreme, general apathy. These cases may show some features of the other forms,
especially anxiety and pessimism, but not to the degree that they cannot rest and recover
in their own unit (duty) or in a nonmedical support unit (rest). However, the tactical
situation may call for them to rest in medical cots if no other suitable place is practical.
b. Anxious. The anxious form is naturally one of the most common, given the danger of
combat. Symptoms include verbal expressions of fear; marked startle responses which
cease to be specific to true threat stimuli and become generalized; tremor; sweating; rapid
heartbeat; insomnia with terror dreams, and other symptoms of hyperarousal. This form is
often seen while the soldier is close to the danger and shifts to the exhausted or depressed
forms as he is evacuated towards the rear.
c. Depressed. The depressed form is also common. It may have the slowed speech and
movement of the simple fatigue form or the restlessness and startle responses of the
anxious form. The depressed form also has significant elements of self-doubt, self-blame,
hopelessness, and may include grief and bereavement. The soldier may be pessimistic
about the chance for victory or survival. The self-blame and guilt may be about perceived
or actual failures in the combat role or mistakes made. It may be related to home front
issues. Or it may be relatively pure survivor guilt -- the irrational feeling of a survivor
that he should have died with members of his unit or in place of a buddy.
d. Memory Loss. The memory loss form is usually less common, especially in its extreme
versions. Mild forms include inability to remember recent orders and instructions. More
serious examples are loss of memory for well-learned skills or discrete loss of memory
for an especially traumatic event or period of time. Extreme forms include disorientation
and regression to a precombat (for example, childhood) state. Total amnesia, or a fugue
state in which the soldier leaves the threatening situation altogether, forgets his own past,
and is found wandering somewhere else (having taken on another superficial identity),
can also occur. Physical causes of amnesia such as concussion or substance misuse (for
example, alcohol) must be ruled out in such cases.
e. Physical Function Disturbance. Disturbance of physical function includes disruptions
of motor, sensory, and speech functions. Physical injuries or causes are absent or
insufficient to explain the symptoms.
o
o
Motor disturbance includes - Weakness or paralysis of hands, limbs or body.
 Sustained contractions of muscles (for example, being unable to straighten
up or to straighten out the elbow).
 Gross tremors; pseudoconvulsive seizures (sometimes with loss of
consciousness).
Visual symptoms may include --
Blurred or double vision.
Tunnel vision.
Total blindness.
Auditory symptoms may involve - Ringing (or other noises) in the ears.
 Deafness.
 Dizziness.
Tactile (skin) sensory changes include - Loss of sensations (anesthesia).
 Abnormal sensations, such as "pins and needles" (paresthesia).
Speech disturbance may involve - Stuttering.
 Hoarseness.
 Muteness.



o
o
o
(1) The physical symptoms often begin as normal but transitory incoordination,
speech difficulties, or sensory disruption. These symptoms are triggered by
physical events, such as explosions, mild concussion, or simple fatigue. They are
magnified when emotions cannot be expressed because of social pressure or
heroic self-image. They are, therefore, most often seen in the "elite" units or
groups who show few other cases of battle fatigue, such as officers or the airborne
and rangers in WWII. They are also more common in individuals from social
classes and cultures that receive less education and/or do not learn how to express
feelings in words.
(2) In some cases, the physical "disability" may have a clear symbolic relationship
to the specific emotional trauma or conflict of motivation which the soldier has
experienced. The disability may make the soldier unable to do his job and so
relieve him from danger, such as classic "trigger-finger palsy." The symptoms
may be reinforced by reducing his anxiety and eliminating internal conflict of
combat duties. Symptoms also may be reinforced by receiving the relative luxury
of rear area food, hygiene, and sleep. However, not all cases fit that pattern. Some
soldiers with significant loss of function from battle fatigue have continued to
perform their missions under great danger. Medical personnel must be alert to
new physical forms of battle fatigue which mimic physical injury, such as might
be attributed to lasers, radiation, or chemical agents.
f. Psychosomatic Forms. These psychosomatic forms of battle fatigue commonly present
with physical (rather than emotional) symptoms due to stress. These include -o
o
Cardiorespiratory - Rapid or irregular heartbeat.
 Shortness of breath.
 Light-headed.
 Tingling and cramping of toes, fingers, and lips.
Gastrointestinal --
Stomach pain.
Indigestion.
Nausea/vomiting.
Diarrhea.
Musculoskeletal - Back or joint pain.
 Excessive pain and disability from minor or healed wounds.
 Headache.




o
According to some WWII battalion surgeons, the psychosomatic form of battle fatigue
was the most common form seen at battalion level. This type of case may have accounted
for a large percentage of all patients seen at battalion aid stations (BASs) during times of
heavy fighting.
g. Disruptive Forms. Disruptive forms of battle fatigue include disorganized, bizarre,
impulsive or violent behavior, total withdrawal, or persistent hallucinations. These are
uncommon forms of battle fatigue, but they do occur. Battle fatigue symptoms are a
nonverbal way for soldiers to communicate to comrades and leaders that they have had
all they can stand at the moment. Battle fatigue takes on whatever form the soldiers
expect. It is important, therefore, to create positive expectancies and to eliminate the
belief that battle fatigue soldiers usually do crazy, senseless, or violent things. Leaders,
medics, and combat stress control personnel must ensure that battle fatigue casualties are
never referred to as psychiatric casualties.
5-4. Labeling of Battle Fatigue Cases
a. As stated earlier, battle fatigue is the US Army approved label for this condition.
Fatigue implies that it is a normal condition which can occur in anyone who is subjected
to the extreme mental and emotional work of combat missions. Fatigue also implies that
it gets better quickly with rest. The term should be applied to the normal but
uncomfortable reactions to combat stress. It should also be used with the more seriously
impairing responses in order that it not take on the connotations of breakdown or a
release from duty. However, some cases do require treatment in medical facilities, skilled
counseling, and even brief tranquilizing or sedative medication.
b. Historical experience proves that it is important not to try to make early distinctions
among battle fatigue cases based on presumed causes and likely response to treatment.
Cases due to acute emotional stress versus subacute physical stress versus chronic
cumulative stress may need somewhat different treatment. These cases have, on the
average, different likelihood for successful return to duty. However, these battle fatigue
cases may be quite impossible to distinguish at first by their appearance and symptoms.
Accurate individual history may be unattainable during battle and especially during the
first interviews. All cases should, therefore, be called battle fatigue and be treated
immediately with positive expectation of rapid, full recovery, as close to their units as the
tactical situation permits. It is essential to avoid dramatic or medical/psychiatric labels for
this condition.
CAUTION
Do not prejudge whether a battle fatigue soldier will recover quickly or slowly based
on initial appearance. The symptoms are very changeable. Do not rely on initial
information about the relative contributions of acute emotional stress, physical
fatigue, chronic exposure, or baseline factors. The incomplete history may be
misleading.
(1) Consider each contributing factor in designing treatment.
(a) How to reassure.
(b) How much rest.
(c) What to replenish first and most.
(d) What activities to assign to restore confidence.
(2) Keep positive expectation for recovery.
(3) Get more validated information from the rested soldier and the unit.
(4) Revise the plan based on response to treatment.
c. Battle fatigue may occur in anticipation of the action, during the action, or after the
action (during lulls when sick call is again possible or when the unit returns to a safe rear
area). Usually, the rise in battle fatigue casualties is preceded by 1 to 3 days of increases
in the number of soldiers wounded and killed. All of these cases are still called "battle
fatigue" as long as the soldiers are in the theater of operations and are expected to recover
and return to duty. The terms conflict fatigue, crisis fatigue, stress fatigue, or field fatigue
may be used for peacetime cases which are reactions to intense mission stressors but do
not involve actual battle or life-and-death consequences. These cases should be treated
the same way as battle fatigue with no negative connotations.
d. Sublabeling of battle fatigue cases is based solely on where they can be treated. Hence,
sublabels depend as much on the situation of the unit as on the symptoms shown by the
soldier. The labels light and heavy, duty and rest, hold and refer, when added to the label
battle fatigue, are nothing more than a short-hand or brevity code for saying where the
soldier is being treated or sent. They have no other meaning and only transient
significance. The sublabel should be updated as the soldier improves or arrives at a new
echelon of care.
e. Figure 5-1 diagrams the choices that lead to the several sublabels for battle fatigue
cases.
Figure 5-1. Diagram of sorting choices and labels for battle fatigue cases.
(1) Light battle fatigue can be managed by self and buddy aid, unit medics, and
leader actions. Most soldiers in combat will have light battle fatigue at some time.
This includes the normal/common signs of battle fatigue listed in the Graphic
Training Aid (GTA) 21-3-4 (available from US Army Training Audiovisual
Support Centers). Light battle fatigue also includes the warning (or more serious)
signs listed in GTA 21-3-5, provided the signs respond quickly to helping actions.
Soldiers with these symptoms do not need to be sent immediately for medical
evaluation and can continue on duty. If the symptoms persist after rest, they
should be sent to their unit surgeon or physician assistant at routine sick call as
heavy.
(2) Heavy battle fatigue (previously called severe) deserves immediate medical
evaluation at a medical treatment facility. The symptoms may be --


Temporarily too disruptive to the unit's missions.
A medical/surgical condition which requires observation and diagnosis to
rule out the necessity for emergency treatment. The medical triager sorts
the heavy battle fatigue soldiers based on where they can be treated.
(3) Duty cases (previously called mild) are those who are seen by a physician or
physician assistant but who can be treated immediately and returned to duty in
their small unit.
(4) Rest cases (previously called moderate) must be sent to their unit's nonmedical
CSS elements for brief rest and light duties; rest cases do not require continual
medical observation.
NOTE
Duty and rest cases are not medical casualties because they are still available for
some duty in their units. However, those heavy cases who cannot return to duty or
rest in their unit the same day are battle fatigue casualties.
(5) Hold cases are those who can be held for treatment at the triager's own
medical treatment facility because both the tactical situation and the battle fatigue
casualties' symptoms permit. This should be done whenever feasible.
(6) Refer cases are those who must be referred (and transported) to a more secure
or better-equipped medical treatment facility, either because of the tactical
situation or the battle fatigue casualties' symptoms. Refer becomes hold when the
soldiers reach a medical treatment facility where they can be held and treated.
NOTE
The hold and refer sublabels of heavy battle fatigue do not necessarily mean that a
soldier is less likely to recover or will take longer to recover than cases treated as
rest. However, the simple fact of holding or evacuation itself often prolongs the
treatment and decreases likelihood of full recovery and return to duty.
f. There is no easy rule for deciding whether any specific symptom of battle fatigue
makes the soldier a case of duty, rest, hold, or refer battle fatigue. That will require
judgment based on -o
o
o
o
o
What is known about the individual soldier.
The stressors involved.
How the soldier responds to helping actions.
What is likely to happen to the unit next.
What resources are available.
Battle fatigue symptoms can change rapidly based on a soldier's expectations. A
successful combat stress control program prevents unnecessary evacuation and shifts
battle fatigue cases from refer to the hold combat neuropsychiatric triage category. More
importantly, it shifts many soldiers from hold category to rest and duty category. This
allows them to recover in their units and keeps them from overloading the health service
support system.
5-5. Severity of Symptoms and Response to Treatment
a. The severity of symptoms and the speed and extent to which they respond to treatment
are directly related to the intensity, lethality, and duration of the battle incidents which
caused them. The following are general planning estimates which may be modified
greatly by specific factors, such as unit cohesion, training, and leadership.
b. Leader and medical personnel in forward areas should expect as many or more soldiers
to present with duty or rest battle fatigue as there will be hold and refer cases. It is
essential that the former not become casualties by unnecessarily evacuating or holding
them for treatment.
c. In general, the more intense the combat, especially with indirect fire and mass
destruction, the more cases become heavy and need holding or referral, and the harder it
is for them to recover quickly and return to duty.
d. Fifty to eighty-five percent of battle fatigue casualties (hold and refer) returned to duty
following 1 to 3 days of restoration treatment, provided they are kept in the vicinity of
their units (for example, within the division).
NOTE
When returned to their original units after successful treatment for battle fatigue, soldiers
have no increased risk of relapse compared to their buddies who have not yet had battle
fatigue. New soldiers who suffer battle fatigue during their first combat exposure deserve
a second chance under supportive circumstances. They are no more likely to breakdown
again than is another new replacement. However, it must be noted that treatment for
battle fatigue will not turn a previously poor soldier into a good soldier. Soldiers who
have accumulated too many terrible experiences may also reach a stage where
reassignment to less dangerous duties is advised.
The variation of success rates between 50 and 85 percent can be due to several factors
besides the intensity of the combat. Combat stress control planners must evaluate them
critically. An 85 percent restoration rate could be the result of effective far forward
treatment of true hold cases. Alternatively, it could occur because many easily treated
cases are being held and rested in medical cots (and classified as hold) instead of being
released to their units as duty or rest battle fatigue. That situation, in turn, could be due
either to inadequate training and consultation to forward units or to a tactical situation
which prevents maneuver units from resting any marginally effective soldiers.
e. Fifteen to fifty percent of battle fatigue casualties do not recover within 72 hours. The
wide variation is due both to the intensity and nature of the battle and to the availability
of far forward treatment. A large number of these battle fatigue casualties (10 to 40
percent of the original total) do return to some duty within 1 to 2 weeks. This is
accomplished only if they continue structured, equally positive treatment. This treatment
may be provided in a non-hospital like atmosphere of a medical treatment (tactical)
facility in the combat zone. Premature evacuation of battle fatigue soldiers out of the
combat zone must be prevented as it often results in permanent psychiatric disability. If
the tactical situation permits, the evacuation policy in the corps should be extended from
7 to 14 days for the reconditioning program, as this will substantially improve the
returned to duty rate and decrease subsequent chronic disability.
f. Five to fifteen percent of battle fatigue casualties fail to improve sufficiently to return
to duty in the combat zone. Further reconditioning treatment can return many of these to
useful duty in the COMMZ. Final evacuation to CONUS should not exceed 5 percent of
total battle fatigue casualties. In retrospect, many of these soldiers have preexisting
personality types or other neuropsychiatric conditions which did not make them become
battle fatigue casualties in the first place but did interfere with full recovery. A lesson
plan on how to identify, treat, and prevent battle fatigue is provided in Appendix E.
CHAPTER 6
POST-TRAUMATIC STRESS DISORDER
6-1. Introduction
a. Over the years, there were sporadic reports of veterans from WWI, WWII, and the
Korean conflict who suffered from persistent war neurosis or exhibited disturbed
conduct. It was not until the late 1970s that PTSD was recognized as a classifiable
psychiatric syndrome. A major driving force was the large number of Vietnam veterans
who were suffering from what was at first labeled post-Vietnam syndrome (a pattern of
symptoms). This syndrome involved varying combinations of anxiety and hyperarousal,
depression and guilt, impulsive or violent behavior, social alienation or isolation, and
often substance abuse. The common theme was the intrusive, painful memories of
Vietnam and the ways the sufferer used to try to avoid or escape them. The post-Vietnam
syndrome was also identified in noncombat military personnel. Similar symptoms and
behavior were recognized in combat medics, hospital personnel and female nurses from
Vietnam (and prior wars), and in ex-prisoners of war and concentration camp survivors.
b. Also in the mid-1970s, a similar syndrome was being recognized in some traumatic
civilian situations, such as victims of natural or human-caused disasters, rape and other
violent crimes, and terrorist acts or hostage-taking episodes. The same symptoms were
found in many cases of burnout in civilian police, fire, and emergency medical personnel.
c. The American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, 1979, established the criteria for making a diagnosis of PTSD.
These were updated in Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised (DSM III-R), Washington, DC: American Psychiatric Association,
1987. See Table 6-1 for specifics.
d. The DSM III-R classification recognizes that PTSD can be -o
o
o
Acute (beginning within 6 months of the traumatic event, but not lasting longer
than 6 months).
Chronic (beginning within 6 months and lasting longer).
Delayed (beginning or recurring after 6 months and perhaps even many years
later).
Delayed PTSD can usually be related to other stressors going on in the person's life at the
time, especially those which remind him of the combat stressors, such as a threat of loss
of life, self-esteem, or love relationships.
e. It should be obvious when comparing the criteria in Table 6-1 with the descriptions of
battle fatigue in Chapter 5 that if a war or operations other than war continues for more
than a month, some of the battle fatigue cases could meet the criteria for a diagnosis of
PTSD. However, by US Army convention, the label PTSD will not be used while the
soldier is in the theater of operations as battle fatigue more clearly implies the positive
expectation of recovery and return to duty without persistent problems. The diagnosis of
PTSD will be reserved for symptoms which persist or arise after the cessation of
hostilities or after returning to the US.
Table 6-1. Diagnostic Criteria for 309.89 Post-Traumatic Stress Disorder
Editor's Note: Coprighted material has been
omitted becuase it is not essential to
understanding of this publication.
6-2. Psychologically Traumatic Events
a. Explanation of Psychological Trauma. Psychological trauma, by definition, involves a
crisis situation which makes the person feel he is changed for the worse. The implication
is that the victim has suffered psychological injury and bears the psychological scars. To
qualify under DSM III-R, the traumatic event must be something which is outside the
range of usual human experience; it is an event which anyone would find horribly
distressing. It is true that for professions like police, fire fighters, emergency medicine
personnel, and the combat soldier many events come to be accepted as routine and even
positive that other people would find unusual and traumatic. There remain, always, those
terrible events (because of chance or mistake) that one hopes (and deep down believes)
will never happen to oneself or one's close friends.
b. Causes Contributing to Post-Traumatic Stress Disorder. Traumatic events tend to be
discrete events which provoke especially vivid memories of terror, horror, helplessness,
failure, disgust, or "wrongness." Even in prolonged stress situations like being a PW or
hostage or serving a medical or mortuary tour in Vietnam, subsequent PTSD will call out
specific bad events. The events often (but not always) involve especially vivid sensory
stimuli which are distinctly recorded in memory -- visual images, smells, sounds, or
feelings. The sense of "wrongness" may be from a personal violation or error, or from a
sudden realization of the arbitrary unfairness in life as it affects others. So, for fire
fighters, the death of children in fires is especially distressing. Combat soldiers who have
killed enemies at long range in open battle with pride may be haunted years later by the
memory of a soldier they killed in ambush. They are haunted because they searched the
body for documents and instead found letters and photographs of loved ones similar to
their own. Mortuary affairs personnel, too, tend to suffer when they inadvertently learn
too much about the lives of the people whose bodies they must handle.
c. Situations Likely to Provoke Post-Traumatic Stress Disorder. The following is a listing
of some of the situations in combat (and civilian equivalents):
o
Loss of friends, buddies, and loved ones - Under especially horrible circumstances.
With associated guilt because of an actual or perceived mistake or an error
(omission or commission).
 By having exchanged places so that a friend went and died instead of
oneself.
Injury or death to innocents (especially women and children).
Seeing grossly mutilated bodies or wounds.
Atrocities (done, condoned, or just observed).
Lack of respect; lack of ceremony and "closure" for deceased friends.
Lack of apparent meaning or purpose to the sacrifice, as might result from
careless accidents or military errors.
Inadequate quality of the homecoming reception which fails to validate the
sacrifices and inhibits talking out the bad memories with family, friends, or fellow
veterans.

o
o
o
o
o
o
d. Symptoms of Post-Traumatic Stress Disorder.
(1) As the DSM III-R criteria (Table 6-1) reveal, PTSD is driven by intrusive
memories of the traumatic event. These may come while awake or in dreams. The
memories may come when a person is intoxicated. Occasionally these memories
can be so vivid and multisensory that the person feels briefly he is reliving the
experience (called a flashback). These thoughts are often triggered by sensory
stimuli like those of the original -- events, such as objects, helicopter sounds, or
smells. They become more intrusive for a while after the initial reminder. Because
the memories are painful, the person with PTSD tries to avoid things that bring
them on and may be quite successful.
(2) The memories themselves do not constitute PTSD. The issue is whether (and
how) they interfere with general well-being, happiness, and occupational or social
functioning. For example, an infantry battalion colonel who had been a company
commander in Vietnam described how he could still not see a piece of trash on
the ground without suddenly becoming alert and being inclined to stay well away
from it. Along with this would be painful, vivid memories of the horrible wounds
which his young soldiers had suffered from booby-trapped trash. The colonel,
however, does not see himself as scarred by those memories. Rather, he reassures
himself that it was a hard lesson he has not forgotten and that if his unit should
find itself in a similar war, he will see that his men do not have to learn this lesson
in such a hard way again. He has reframed the painful memories in his mind so
that they resulted in positive growth rather than an unhealed scar.
(3) The colonel (mentioned above) did say that for several years after returning
from Vietnam, he had experienced other symptoms which approached those of
PTSD. He felt isolated and alienated from other people, especially from civilians
and other Army coworkers who had not been in Vietnam. He felt they could not
understand what it was like and did not want to hear about it. He felt considerable
anger towards them and held his temper chiefly by keeping to himself. He also
tended to shut out his wife and children that way for a while.
(4) In more extreme cases, the isolation takes the form of an inability to feel
affection or form close relationships. In losing close friends in combat, the soldier
learned not to get too close again to the new replacements. The pattern has
continued involuntarily. Negative feelings towards women and children (such as
mistrust combined, perhaps, with guilt) may also have been acquired by the types
of interactions encountered in the combat zone. The veterans with PTSD may go
emotionally numb, continuing to function without any feeling when something
happy or sad occurs.
(5) The angry and hostile feelings may stay tightly suppressed, as in the infantry
colonel's experience described above, or they may erupt in angry outbursts or
even in rage and violence. The ex-combat soldier who was once authorized to use
lethal force in combat missions (and perhaps went beyond that to exercising force
in the form of misconduct stress behaviors) has the memory of that power to
provide temptation or self-justification for using violence again. This is especially
likely when inhibition is impaired by alcohol or other intoxicant drugs. See
Chapter 4 for details on misconduct stress behaviors.
(6) Substance abuse, especially alcohol, is common with PTSD. It provides an
escape from or dulling of the memories. It is often used to try to get to sleep
without the bad dreams and to reduce the anxiety and tension.
(7) Post-traumatic stress disorder characteristically involves symptoms of anxiety
and hyperarousal -- exaggerated startle responses or excessive alertness and
vigilance for potential threats. These may be the threats of the past combat
situation (such as the colonel's alertness about the trash or automatically noting
potential ambush sites), or it may lead to excessive suspicion and caution in daily
life (such as sleeping with a loaded pistol under the pillow or never sitting with
one's back to a crowded room).
(8) Depressive symptoms, with poor sleep, loss of appetite and other pleasures,
poor concentration, and guilt feelings are also characteristic of true PTSD. The
sufferer is preoccupied with what he did or did not do to survive when others
died. He may blame himself for mistakes that were real or quite beyond his
control. He may have guilty thoughts, such as "If only I had not been so slow" or
"If only I had been six feet closer, I would have seen that sniper before he shot my
friend." The risk of suicide in PTSD is related to this depression and should not
go unrecognized. It may also lead to reckless, potentially self-destructive behavior
without conscious suicidal intent.
e. Early (Preventive) Treatment of Psychological Trauma.
(1) An analogy has been made between psychic trauma and physical trauma, such
as lacerated muscles and broken bones. People sometimes try to reassure the
traumatized victim with the saying, "Time heals all wounds." This reflects the
common observation that feelings of grief, loss, and guilt do normally tend to fade
with time. But the analogy with physical wounds suggests the fallacy in such
reassurance.
(2) Time heals broken bones, but only if they have been carefully realigned and
stabilized to permit correct healing to begin. Time heals lacerated muscles, but
only if they do not become badly infected by bacteria and dead tissue trapped in
the wound. One of the most important lessons of combat wound surgery is not to
attempt immediate primary closure (stitching the muscle and skin together again)
as would be done in civilian hospital surgery. Instead, it is better to leave the
wound open, keep it clean, and let it heal from the inside out for a few days. It can
then be closed under sterile hospital conditions to decrease the size of the scar.
(3) With especially traumatic physical injuries, such as high-velocity bullet
wounds, the surgical treatment is even more stringent. The surgeon provides
immediate intervention to stop the bleeding. He then debrides dead tissue and
surgically repairs the wound. In many cases the surgeon may delay primary
closure and insert a drain which allows the wound to heal from the inside out.
(4) This analogy between physical traumatic injury and psychic traumatic stress
appears accurate regarding immediate treatment. It is best not to attempt
immediate primary closure of psychic trauma by forcing the feelings out of mind
and pressing on with other tasks that keep the disturbing feelings from surfacing.
Instead, it is better to open up the psychic wound and let it drain. It may even be
necessary to "insert a drainage tube" (to permit proper healing) -- that is until the
sufferer actually feels and expresses the suppressed, painful emotions and allows
them to come out. This should be done as soon as the soldier who is suffering can
pull back from the mission safely and regain (through brief rest and physical
replenishment) the strength and clarity of mind needed to participate in his
therapy.
(5) Another analogy perhaps more familiar to the nonmedical leader is the
preventive maintenance of complex equipment. A good officer or NCO would not
accept bringing an MlA1 tank (or an M16 rifle) back from fighting in a sandy
desert or muddy/salt marsh without performing maintenance. This maintenance
includes cleaning, re-oiling, and preparing the MlA1 tank for its next mission.
The good leader knows that even though the dirt has not already jammed the
weapon, the salt particles or sand grains will greatly increase corrosion and wear.
The result could be unreliable performance, increased maintenance costs, later
catastrophic failure, or maybe just a decreased useful life. Especially traumatic
memories can have the same corrosive effect on the individual. They can impair
the soldier's future performance. They can result in much unnecessary pain and
suffering, both to the soldier and his family.
f. Small Group After-Action Debriefing.
(1) Every small unit leader should routinely conduct after-action debriefings
following any difficult situation. This is especially important if mistakes or
misunderstandings occurred or losses were suffered. After-action debriefing for
stress control may be integrated into the routine after-action review if the time
available does not permit the separation of the two.
(2) The after-action review should be practiced in training and continued in
conflict or war. The after-action review should be conducted as soon as it is safe
for the leader to bring his team together. The purpose of the after-action review is
to talk about the details of the recent action and agree on lessons learned. The first
step is to agree on what actually happened. It may be necessary to share
everyone's observations to get a clear picture. The after-action review focuses on
how well the battle/crew drill or TSOP worked. What went well and needs no
change? What could use further improvement? What did not work at all and needs
a new approach? When properly conducted, the after-action review increases
understanding, trust, and cohesion within the team. It builds confidence that future
events be handled even better.
(3) The after-action debriefing process shares the after-action review's concerns
with details of what happened. It goes further by actively encouraging the team
members to share and talk out their emotional responses to the event. After-action
debriefings should also be routine during training, operations other than war, and
war following any difficult or unpleasant event. Doing after-action debriefing
routinely will make them second nature following any especially traumatic event.
The objective of after-action debriefings following traumatic incidents is to
promote "healing" by opening up, "cleaning and draining" any unpleasant or
painful memories. Table 6-2 lists the key steps of the after-action debriefing
process and Appendix A provides additional information.
(4) Leaders and buddies have the responsibility of continuing to talk through
especially traumatic events. This should be done in a supportive way to
individuals who show signs of distress in the after-action debriefings through
personal conversations. Unit ministry teams may be helpful in the debriefings and
in individual pastoral counseling to help the soldier redirect the painful memories
toward positive spiritual growth. Individual referral to mental health/ combat
stress control personnel is indicated for severe distress.
Table 6-2. Key Steps in an After-Action Debriefing
g. Following Up the After-Action Debriefing.
(1) People who live through extremely traumatic experiences should not expect to
forget them. It is entirely normal to remember such events with sadness,
resentment, guilt, or whatever emotions the event deserved. It may be appropriate
to atone for mistakes made. It is also normal to dream about the event, even many
years later. The "normal" pattern is for these painful feelings to become less
intense and less frequent as they are balanced by later, positive events.
(2) Combat stress control/mental health personnel should always be notified
whenever serious psychological trauma has occurred in a unit. They can assist
command in assuring that the after-action debriefing process is done correctly.
When indicated, the unit should arrange for combat stress control/mental health
personnel to conduct a critical event debriefing. Critical event debriefings are
similar to after-action debriefings but differ in the following ways:


The critical event debriefing is led by a trained debriefer who is not a
member of the unit being debriefed; the after-action debriefing is led by
the small unit's own leader.
The critical event debriefer explicitly defers issues of operational lessons
learned in order to focus on the stress aspects and stress responses; the
after-action debriefer does seek to capture relevant operational lessons
learned in positive terms.
(3) Prior to redeployment home, units should schedule time for everyone to
verbally review the high and low points, talk through any unresolved issues, and
conduct memorial ceremonies, if appropriate. Chaplains and combat stress
control/mental health personnel should also take an important supportive role in
these activities.
h. Cautions for Preventive Intervention After Traumatic Stress.
(1) The analogy between PTSD preventive interventions and traumatic wound
surgery suggests a cautionary warning. If the surgery is not done skillfully, it can
cause more harm than good, leaving dead tissue and bacteria in the wound. It may
cut away tissue that did not need to be sacrificed, or realign the broken bones
incorrectly. The same is potentially true for poorly executed after-action
debriefings or critical event debriefings.
CAUTION
A poorly executed stress debriefing can cause harm. It can -


Leave important and painful issues unexplored, waiting to
fester into future PTSD which will be harder to treat.
Compound rather than relieve the feelings of guilt, anger, and
alienation.
Glamorize and encourage chronic PTSD disability.
(2) The problem for early prevention efforts is to forewarn of possible posttraumatic stress symptoms without glamorizing them or advertising them as a
reimbursable longterm disability. To do the latter invites malingering. It also
subtly encourages those who do have real but not disabling post-traumatic
symptoms to magnify them. This will be especially likely if they have other
psychological issues or grievances which the symptoms also address, such as
feeling unappreciated for the sacrifices suffered or guilt at having left their
buddies.
(3) As with the treatment of acute battle fatigue, it is essential that all persons
involved in preventive or treatment interventions for PTSD express positive
expectation of normal recovery. At the same time, they must indicate that
continuing or recurring symptoms can and should be treated, still with positive
expectation of rapid improvement. They should advise that post-traumatic stress
symptoms may recur in the future at times of new stress. Successful treatment
after future episodes should deal with the ongoing, new stressors as much as with
the past trauma.
6-3. Identification and Treatment of Post-Traumatic Stress Disorder After the War
a. Because PTSD can recur months or years later (usually at times of added stress),
coworkers and supervisors, chaplains, and health care providers should all be alert to the
often subtle signs of PTSD long after combat. They should provide normalizing support
and encourage (or refer the soldier for) mental health treatment.
b. Remember, one of the common symptoms of PTSD is social alienation, withdrawal,
and attempts to avoid reminders of the memories. Sufferers of post-traumatic stress
symptoms are, therefore, not likely to volunteer their combat history or to admit easily to
the "weakness" of not being able to control their painful memories. In fact, many soldiers
with PTSD from prior combat (or accident or disaster) present as cases of substance
abuse, family violence, or other misconduct. They will not receive the mental health help
they deserve unless the causal stress relationship is explicitly asked about and recognized.
c. Another hidden cost of inadequately treated post-traumatic stress will be the potentially
large number of combat-experienced veterans (especially in the elite units) who either ask
for transfer out of the combat unit, do not reenlist, or submit resignations. They will often
say "My spouse wants me to leave the Army, and was especially worried that I almost got
killed in that last deployment." Only with careful exploration will it become clear that the
spouse is not upset with the Army or its risks but because the soldier came home
changed. He keeps to himself, will not say what is wrong, gets mad at the children, drinks
too much, and wakes up at night shouting and crying. The spouse thinks that if the soldier
can only get away from the Army, he will get back to the way he was before.
Unfortunately, if simply allowed to resign, whatever guilt, shame, or other traumatic
memory is haunting him will probably continue unresolved.
6-4. Combat Stress Control (Mental Health) Personnel Responsibilities
a. Combat stress control personnel have critical roles in assisting command in the
prevention and early recognition of PTSD and in treatment of the individuals to avoid
long-term suffering or disability following traumatic combat experiences. Treatment is
often best when conducted in groups. The Department of Veterans Affairs (veterans'
counseling centers) also may provide valuable consultation and treatment expertise.
Whenever the Department of Veterans Affairs is involved, however, special care should
be taken to avoid the negative expectation of long-term treatment and chronic disability
reimbursement.
b. Post-traumatic stress disorder also occurs following natural and accidental disasters,
terrorist attacks, rape or criminal assault, and hostage situations. Mental health/combat
stress control teams have consistently demonstrated their value in rapid deployment of
medical response teams for such contingencies. Their involvement following such
incidents, as well as following combat, should be requested by the chain of command
according to standing operating procedure.
CHAPTER 7
STRESS ISSUES IN ARMY OPERATIONS
7-1. Introduction
This chapter reviews Army operational concepts for how we will fight. It highlights specific
stressors that can contribute to decreased effectiveness, battle fatigue casualties, or misconduct
stress behaviors. The chapter summarizes a number of other doctrinal manuals. For those readers
who are already familiar with those manuals, it will highlight stress issues which were not
explicitly stated in the original sources. For those readers who are not familiar with the source
manuals, this chapter provides a hasty "one-stop" reference source. However, they are strongly
encouraged to continue their education in the original references. All leaders must understand
these operational realities and the words used to describe them. Leaders at all levels work closely
with each other so they may be able to anticipate the stressors and prevent stress casualties.
7-2. Overview of the Challenges
a. Army Missions. Army forces must meet worldwide strategic challenges against the full
range of threats within highly varied operational theaters. In areas of greatest strategic
concern, the Army must be prepared to fight battles of unprecedented scope and intensity.
The operations surrounding such battles will routinely involve cooperation with other
services and allies. While the threat of tactical nuclear war has decreased, it may be
present in some confrontations. The threat of functioning on a chemical or biological
battlefield remains a possibility in any conflict, anywhere in the world.
NOTE
Every scenario involves its own unique combination of stressors which must be
controlled to assure that our forces function at their best.
b. Joint and Combined Operations. The nature of modern battle and the broad dispersion
of US geographical interests require joint operations by US forces. It is imperative that
Army units fight as part of a joint team with units of the US Air Force, the US Navy, and
the US Marine Corps. We must cooperate with representatives of civilian and
government agencies. These agencies may include the State Department, Central
Intelligence Agency, Federal Bureau of Investigation, Red Cross, United Nations, and
international relief agencies. It is also critical that commanders prepare themselves and
their troops to fight in coalition/ combined warfare alongside the forces of our nation's
allies. Teamwork in joint and combined operations will be necessary in any battle the
Army forces fight, as well as in operations other than war.
(1) Leaders must take active steps to counteract prejudices, disrespect, mistrust,
and doubt about the reliability and competence of other services and allies. It is
extremely important that soldiers respect those beliefs that are different from our
own and respect the customs and practices of people in other nations. Unchecked
prejudices, disrespect, mistrust, and doubt can lead to high battle fatigue
casualties or to misconduct stress behaviors which could damage the coalition.
(2) When directed by the national command authority (NCA), the Army may need
to assist a less-developed host nation (HN) in setting up an effective stress control
or community mental health/social services system. This system may be for its
Armed Forces, refugees, and/or civilian population.
c. Forward Presence Versus Contingency Operations. Army operations in the foreseeable
future will be fought in one of two basic environments.
(1) One environment may be an anticipated theater of war with an existing
support structure of communications, air defense, logistic facilities, and ports.
Service families may be present in the theater before the conflict. Their presence
adds additional concern for their security and for noncombatant evacuation
operations. The troops and their families must have confidence that the chain of
command can be trusted to implement a workable plan to assure the safety of the
families. Otherwise, the soldiers' first concern will be the safety of their family
rather than mission accomplishment.
(2) The other environment may be a relatively austere theater. In this
environment, Army leaders will have to choose between creating such a support
base or fighting with only external support. Contingency operations are military
actions requiring rapid deployment in response to a crisis. Contingency operations
involving Army forces may provide a rapid show of force in support of a
threatened ally to deter aggression by a hostile neighbor. Contingency operations
react to the invasion of a friendly government, protect lives and property of US
nationals, rescue hostages, or perform other tasks as directed by the NCA. The
size of a contingency force, its mission, and its area of operations will vary.
(a) Rapid deployment itself involves much physical and mental stress
during preparation and transportation. If the deployment crosses many
time zones, there is the added disruption of the body's biological daynight/workrest cycles.
(b) The necessity for secrecy in contingency operations puts great stress
on the soldiers who are suddenly "sealed in." Great stress is also placed on
their families with whom they cannot communicate. Leadership must
ensure and support the establishment of family support groups. They must
also be sensitive to the needs of families to learn about the involvement of
their spouses in particular military operations. Stress control leader actions
are discussed in Appendix A.
d. Austere Support. Army forces must be prepared to fight their battles at the end of long,
vulnerable lines of logistical support, with limited availability of airlift and sealift. They
must anticipate high consumption rates for all supplies. They may have to fight
outnumbered against an enemy with significantly shorter supply lines. This may be true
for leading US echelons even in a contingency operation against a distant opponent much
smaller than the United States. Logistical support may be austere in such situations and
thereby markedly affect the design of campaigns and the planning and conduct of battles.
NOTE
Shortages and uncertainties of resupply contribute to low morale and high rates of battle
fatigue casualties unless troops are psychologically prepared to improvise. Once apprised
of the situation, they must believe that everything feasible is being done to support them.
e. Urban Combat. Combat in built-up areas will be unavoidable in war and operations
other than war (conflict). Units will have to plan for attack and defense in urban areas and
for fluid battles around them. The usual static, house-to-house nature of urban warfare,
with many snipers, mines, and booby traps, tends to increase battle fatigue casualties
unless troops are well-trained and led. Built-up areas are also likely to provide
temptations for looting, alcohol and substance abuse, black marketeering, and harmful
social interactions. Preventive measures must be in place to avoid these temptations. For
more detailed information, refer to FMs 90-10 and 90-10-1.
f. Presence of Civilians and Rules of Engagement. The likely presence of civilians in
combat areas can have diverse effects. Seeing and perhaps accidentally inflicting
casualties on civilians (especially if they are women and children) increases battle
fatigue, especially if the civilians are perceived as friendly. If the civilians are hostile, or
have been infiltrated by enemy partisans, the potential for misconduct stress behaviors is
high unless strong unit cohesion and a sense of ethical purpose protects against it.
g. Continuous Operations. Continuous land combat is an advanced warfare concept made
possible by the almost complete mechanization of land combat forces. It is also made
possible by the technology that permits effective movement and target detection at night,
in poor weather, and in other low-visibility conditions. Combat can continue around the
clock at the same high level of intensity for extended periods. Armies now have the
potential to fight without letup. The reasons that have traditionally forced a pause -darkness, resupply, regrouping -- have been largely overcome by technological advances.
Thus, CONOPS is more possible due to advanced technology, and the demands of such
operations are very stressful. However, the possibility of failure of the sophisticated
devices can also be a great stressor. Soldiers who become dependent on the technology in
their military occupational specialty could feel extremely vulnerable should the
equipment fail. Where possible, soldiers should be taught how to accomplish the task
without the device so that its failure would not be so catastrophic. Refer to FM 25-101 for
doctrine on battle-focused training. For recommendations related to CONOPS leader
actions, see FM 22-9 and Appendix A of this FM.
h. Sustained Operations. The term sustained operations (SUSOPS) is used when the same
soldiers and small units engage in CONOPS with no opportunity for the unit to stand
down. This permits very little opportunity for soldiers to catch more than a few minutes
of sleep under disruptive conditions. Weapons systems can operate day and night, but
must be refueled, rearmed, and repaired by soldiers for their operations. Soldiers need
water, food, hygiene, and sleep just as the machines need refueling and preventive
maintenance. Sustained operations should be avoided whenever possible except for brief
periods, when forced by enemy action or accepted by command as essential to maintain
pressure on a disintegrating enemy or catch him at a disadvantage. Sustained operations
must always be considered carefully as a calculated risk. Leader actions when SUSOPS
must be undertaken are discussed in Appendix A.
NOTE
Sustained operations place significant emphasis on the leaders' abilities to implement
effective sleep plans (which include the leaders) and on crosstraining of soldiers so they
can perform a variety of roles during combat operations. Continuous operations do not
necessarily involve SUSOPS if sufficient units (or individuals within units) are available
to allow everyone to get adequate rest. Leaders must be aware that SUSOPS quickly
deplete the combat effectiveness of units physically, logistically, and psychologically.
For CONOPS, plans must be in place to relieve spent units and redesignate missions to
other less depleted organizations.
7-3. The Potential Battlefield
a. The threat will vary according to the intensity and location of the conflict. A European,
Southwest Asian, and possibly Northwest Asian scenario would most likely be a highintensity environment. This environment would be characterized by broad frontages, deep
targets, and enemy penetrations of varying depths. Operations other than war (conflicts)
are usually associated with Third World countries. These conflicts would be
characterized by poorly defined frontages, semiautonomous dismounted operations
conducted at varying depths, and rear area security problems.
b. Each environment would challenge (stress) friendly logistics -- including medical -- in
terms of distances and amounts required. Each environment would also provide
opportunities for deep strikes, long-range unconventional operations, and terrorism.
Prepared airfields, permanent bases, and fixed support facilities (including medical units
and facilities) will become primary targets for opposing forces. In the wartime
environment, such facilities may not survive. In the operations other than war
environment, logistical and command centers may have to be highly centralized for
defense, thus lengthening already long lines of communications.
7-4. Army Operations Doctrine: Implications for Combat Stress
a. Basics of Army Operations.
(1) Army operations described in FM 100-5 (the Army's keystone doctrinal
manual) emphasize battlefield success through five basic tenets -- initiative,
depth, agility, synchronization, and versatility. These tenets apply to everyone and
every unit in the Army. Table 7-1 identifies each tenet, the stress issue associated
with that tenet, and recommended actions for commanders and leaders.
(2) The most violent and high-risk environment is that of war with its associated
combat operations.
b. Opposing Forces on the Battlefield. The opposing forces on the modern battlefield will
rarely fight across orderly, distinct lines. Massive concentrations of forces and fires will
make penetrations all but inevitable and will result in a nonlinear battlefield. There may
be little distinction between rear and forward areas.
c. Reliance on Traditional American Military Qualities. Army operations doctrine utilizes
the traditional military qualities of skill, tenacity, boldness, and courage, together with the
technological prowess, self-reliance, and aggressive spirit which characterizes the
American soldier. While respecting the increased complexity and lethality of modern
weapons, Army doctrine recognizes that such weapons are no better than the soldier's
skill and mastery he brings to bear on the enemy.
7-5. Endurance/Staying Power on the Battlefield
In addition to initiative, agility, depth, synchronization, and versatility, Army operations will
demand endurance. Endurance is the ability of a force to sustain high levels of combat potential
relative to its opponent over the duration of a campaign. American soldiers have proven their
staying power under adversity. This quality of endurance can make the difference between
victory and defeat.
Table 7-1. Combat Stress Issues and the Battlefield Imperatives
Table 7-1. Combat Stress Issues and the Battlefield Imperatives (continued)
Table 7-1. Combat Stress Issues and the Battlefield Imperatives (continued)
CHAPTER 8
STRESS AND STRESSORS ASSOCIATED
WITH OFFENSIVE/DEFENSIVE
OPERATIONS
8-1. Introduction
The effects of stress and stressors associated with offensive and defensive operations are
immense. Leaders must understand how high levels of stress can affect the performance of their
personnel in offensive and defensive operations.
8-2. Offensive Operations
a. Fundamentals. (See FM 100-5 for details.)
(1) The offensive is the decisive form of war -- the commander's ultimate means
of imposing his will upon the enemy. Even in the defense, seizing the initiative
requires offensive operations. Combat service support units, by the nature of their
missions, will usually be in tactical defense even while the units they support are
on the attack. However, the likelihood of rear battle requires that all leaders fully
understand the principles, tactics, and psychological advantages of going on the
offense.
(2) Commanders, while shielding their own troops from stress, should attempt to
promote terror and disintegration in the opposing force. Aggressive patrolling,
raids, and sudden, violent actions (which catch the enemy by surprise and do not
permit him to recover) should be common tools to magnify the enemy's battlefield
stress. Stress-creating actions can hasten the destruction of his combat capability.
Some examples of stress-creating actions are attacks on his command structure;
the use of artillery, air-delivered weapons, smoke; deception; psychological
warfare; and the use of special operations forces. Such stress-creating actions can
hasten the destruction of the enemy's capability for combat.
b. Purposes. While offensive operations may have as their objective the destruction or
neutralization of an enemy force, inflicting physical damage is frequently incidental to
offensive success. Large gains are achieved by destroying the coherence of the defense,
fragmenting and isolating enemy units in the zone of the attack, and driving deep to
secure operationally decisive objectives. These have the result of "stressing out" the
enemy defenders.
c. Characteristics. The most successful offensive operations are characterized by
surprise, concentration, speed, flexibility, and audacity.
d. Phases. The four general phases of offensive operations are preparation, attack,
exploitation, and pursuit.
e. Forms of Maneuver. Just as similar phases are common to all offensive operations,
similar forms of maneuver are common to all attacks. These forms of maneuver include
envelopment, turning movement, infiltration, penetration, and frontal attack.
f. Conducting Offensive Operations. Offensive operations are characterized by aggressive
initiative on the part of subordinate commanders, by rapid shifts in the main effort to take
advantage of opportunities, by momentum, and by the deepest, most rapid destruction of
enemy defenses possible.
g. Offensive Framework. A simple, complete concept of operation is the basis of all
tactical offensive actions.
8-3. Battle Fatigue and Battle Fatigue Casualties in the Offense
a. The preparation for an attack is a time of high stress and anxiety, both for novice
soldiers and for veterans. Physical stress complaints (musculoskeletal, cardiorespiratory,
gastrointestinal) are common at sick call. If morale is low and troops are pessimistic
about the attack, battle fatigue casualties and misconduct stress behaviors may be high.
b. There may be much stress and physical fatigue in the attack, exploitation, and pursuit
phases; but relatively few battle fatigue casualties occur as long as soldiers are able to
continue moving and advancing. Battle fatigue casualties increase if the advance bogs
down, is pinned down, or loses momentum, especially when indirect fire is received.
Being bombed or shelled in the starting line is notoriously disruptive, as is being hit by
friendly fire (a risk inherent in a fluid fast-moving battle). Diversionary attacks or
security operations may lack the strong psychological motivation of the main attack and
require additional positive explanation by leaders to minimize adverse combat stress
behaviors.
c. Units in reserve have the difficult task of maintaining fighting spirit and readiness.
While not yet fighting, they are at risk but must try to stay rested. The junior troops
usually get some sleep if they are not too apprehensive. The leaders often do not get
enough sleep because of the never-ending planning and briefing cycle. It is most
important that leaders do plan for and get enough sleep themselves and maintain good
hydration and nutrition.
d. Combat support and CSS troops (especially supply, transport, maintenance, and
medical) may be tasked for prolonged SUSOPS, with increased risk from enemy forces
which were bypassed. They tend to have more battle fatigue casualties per WIA than the
combat arms when they do take casualties. Seeing (and especially having to touch) the
maimed bodies left behind by the attack may produce battle fatigue (and/or future PTSD)
in inadequately prepared troops even if they are not themselves under fire.
e. Every effort should be made to provide rest in the combat and field trains for exhausted
soldiers. Restoration treatment for battle fatigue casualties should be at medical treatment
facilities as close behind the attack as possible. This should generally be possible in the
division support area and brigade support area.
f. Misconduct stress behaviors which constitute criminal acts such as looting, killing
EPW, rape, and other atrocities against noncombatants and "liberation" of alcohol and
drugs are always a risk when victorious troops advance into enemy territory. Leaders
must lead by example and retain control, discipline, and a sense of pride to preclude such
behavior.
8-4. Defensive Operations
a. Fundamentals. (See FM 100-5 for details.) Defensive operations retain ground, gain
time, deny the enemy access to an area, damage or defeat attacking forces, and save one's
own units.
b. Purposes. The immediate purpose of any defense is to defeat the attack.
c. Characteristics. In any defensive plan, preparation, disruption, concentration, and
flexibility are fundamental.
d. Defensive Patterns. While defensive operations may take many forms, traditional
usage divides defensive arrangements into two broad categories: mobile and area
defenses.
e. Defensive Framework. A simple, complete concept of operations is the basis of all
defenses. Defenses are organized into five complementary elements:
o
o
o
o
o
Security force operations.
Defensive operations.
Reserve operations.
Deep operations.
Rear operations.
NOTE
Each of these five defensive elements entails different stress for the defending
troops and may evoke different combat stress behaviors.
f. Retrograde Operations. A retrograde operation is a movement to the rear or away from
the enemy. Retrograde operations are executed to gain time, preserve forces, avoid
combat under undesirable conditions, or draw the enemy into an unfavorable position.
8-5. Stress, Battle Fatigue, and Battle Fatigue Casualties in the Defense
a. Stressful Uncertainties. Defensive operations involve more stressful uncertainty about
enemy intentions and capabilities than being on the offensive. The defensive posture
itself implies that the enemy has the greater strength. Rumors and appraisals of the
situation are more likely to be pessimistic and may overmagnify the true threat.
b. Mobile Defenders. Mobile defense incurs more physical fatigue, but soldiers are less
likely to become battle fatigue casualties. Even in such obviously high-risk situations,
such as a covering force in contact with an overwhelmingly strong attacking enemy, a
positive unit identity and cohesion can provide remarkable protection against fear.
Problems with battle fatigue and misconduct stress behaviors are more likely to occur
later in the survivors who make it back to a safe location -- these may cause difficulties
for reconstitution of the units.
c. Static Defenders. The stressors in static defense vary with the degree of comfort and
security provided by the fortifications. If very strong, the fortifications may increase
confidence to the point of complacency and degraded vigilance; if less strong and
subjected to intense or prolonged bombardment, static defense incurs high battle fatigue
casualty rates. Discomfort, especially cold, wet conditions with inability to move around,
increases both cold injury and battle fatigue casualties.
d. Hidden Stress Casualties (in Retrograde Operations). There are relatively few
diagnosed battle fatigue casualties in retrograde operations. There may be many
undiagnosed battle fatigue soldiers. Some of these soldiers may be ineffective; others
may be a loss to their unit as a result of becoming a PW, MIA, WIA, or KIA. Misconduct
stress behaviors, such as alcohol abuse, desertion, or criminal acts (looting, rape,
atrocities, and the murder of leaders), may occur if the retrograde operation becomes
disorganized. The danger of retreat is that it may degenerate into mass panic or rout with
every man (or small team) trying to save himself at the expense of the others. Such panic,
spread by fleeing soldiers and fanned by rumor, is contagious. Unless checked quickly, it
leads to the catastrophic failure of entire armies and the nation, as befell France under the
German blitzkrieg of 1940.
CHAPTER 9
COMBAT STRESS CONTROL IN
OPERATIONS OTHER THAN WAR
9-1. Introduction
The Army classifies its activities during peacetime and conflict as operations other than war.
Conflict is characterized by hostilities short of war to secure strategic objectives.
a. The growing incidence of conflict pits Army forces against irregular or unconventional
forces, enemy special operations forces (SOF) and terrorists. Conflict poses a threat to
US interests at all times, not just in periods of active hostilities. United States citizens,
especially military personnel and their families, may be at risk anywhere in the world.
b. The terrorist or guerrilla forces count on fear and terror as their principal weapon and
objective. By attacking the defending military forces and civilian population only at times
and places of their choosing, they deny the defender any safe areas and flaunt the
inability of the authorities to protect themselves or their people. By hiding among the
populace and using women and children as combatants, the guerrilla or terrorist provokes
the defending forces to perceive the people as unworthy of protection. The defender may
adopt harsh repressive measures and commit atrocities which turn the people against the
defenders.
(1) Although the stressors of terrorism and guerrilla tactics are less overwhelming
than those of war, they are deliberately designed to cause breakdown of military
professionalism and discipline. As these events are reported in the media, the
enemy expects that the home front in the US will perceive the conflict as
unwinnable and immoral. The goal for the enemy is for the US home front to
abandon support for the effort and even turn against our own soldiers.
(2) In operations other than war when combat operations are required
(engagements), battle fatigue casualty rates rarely exceed one battle fatigue
casualty per ten WIA. Other misconduct stress behaviors, including drug and
alcohol abuse and criminal acts, become the more common and serious reflectors
of combat stress in light combat operations. Table 9-1, page 9-3, lists some likely
stress-producing aspects of operations other than war which involve conflict.
(3) Civil and military leaders would be in error to rely only on military technology
and indiscriminate firepower to oppose a guerrilla force. These leaders must also
recognize and defuse the political and psychological stress threat. If they fail to do
this, they may win the battles in the field but still lose the war (or the post-treaty
peace).
c. Forces for military operations other than war must be selected and task-organized to fit
the situation. Combat, when it occurs, is strategically defensive and intended to permit
political, social, and economic development activities. The nature of the conflict requires
that coercive measures be the minimum necessary to achieve the purpose. This will be
visible to the soldier largely in terms of extremely restrictive rules of engagement. For his
own sake, as well as for the success of the mission, the soldier must understand the
environment in which he is to operate and fight.
(1) Army actions in operations other than war must be fully coordinated with
national strategy and fused at the operational level into a coherent effort. The
effort must complement economical, political, and military activities. This linkage
with such activities must be made clear to the soldiers. Failure to do so can lead to
confusion and frustration among soldiers as to the purpose, attainability, and
objectives of their mission.
(2) Public affairs plays a critical role in the operations other than war
environment, across all of the operational categories. It supports the commander
and soldier by -




Assessing information needs.
Formulating messages.
Facilitating the flow of information.
Providing communications channels.
Serving as the primary interface between the military and the civilian
media.
A key public affairs mission is to reduce the soldiers' sense of isolation by -


Reinforcing the role each soldier plays in the operation.
Ensuring information flows in and out of the theater.
Telling the Army story to the public in order to maintain support for the
effort and the soldiers.
(3) Operations other than war (peacetime or conflict) require that the plan and the
task organization of units be tailored to the specific operation. The following
paragraphs review the operational categories and the special stressors that soldiers
are likely to encounter.
9-2. Support for Insurgency Operations
a. Support for insurgency is a goal-directed activity. These operations are normally of
long duration and predominantly conducted by indigenous or surrogate forces. These
forces are organized, trained, equipped, supported, and directed in varying degrees by an
outside source. Unconventional warfare, a tactic employed in insurgency or
counterinsurgency, includes guerrilla warfare and other direct offensive, low-visibility,
covert, or clandestine operations. It also includes the indirect activities of subversion,
sabotage, intelligence collection, evasion, and escape. The primary forces used in
unconventional warfare are SOF. Combat stress control personnel who support such
operations must have the appropriate level of security clearance to debrief and treat SOF
personnel at the conclusion of their mission.
b. Insurgency is an organized, armed, political struggle whose goal may be the seizure of
power through revolutionary takeover and the replacement of the existing government. In
some cases, however, insurgency is undertaken to break away from government control
and establish an autonomous state within traditional ethnic or religious territorial bounds.
It may even be conducted to extract limited political concessions that are unattainable
with less violent means.
(1) The existing government will attempt to isolate the insurgents from the
general population. Therefore, insurgents normally must live under austere or
primitive conditions, have limited or no access to medical care, and often operate
using hit-and-run tactics. The severity of those conditions will depend upon how
much support the insurgents receive from the local population and the
effectiveness of the government's repressive measures.
(2) If the US SOF were to provide support to a US-backed insurgent group, they
would also operate and live in this austere environment. Issues which would
contribute to combat stress, battle fatigue, and potential misconduct stress
behaviors are listed in Table 9-2 along with leader and buddy actions to
counteract these stressors.
Table 9-1. Stress-Producing Aspects of Operations Other Than War (Conflict)
(3) Insurgents frequently adopt terrorism as a tactic. This is one of the things that
makes counterinsurgency so difficult. It also makes support for insurgency
(should we be called upon to do it) such a moral dilemma.
(4) Insurgencies and use of terrorism independent of insurgencies probably pose
stress which is as severe as that which occurs in the most violent of
"conventional" wars. All the societal norms which Americans accept seem to be
abandoned and perhaps irrelevant. The participants' moral compass may go
haywire so that they have a hard time distinguishing right from wrong. Innocent
persons are singled out for the most atrocious attacks because of their shock
value.
(5) Inspired, compassionate leadership and firm discipline are required to prevent
misconduct stress behaviors.
Table 9-2. Stress Considerations and Recommendations for Stress Control in Insurgency
Operations
9-3. Support for Counterinsurgency Operations
Internal Defense and Development (IDAD) strategy is the full range of measures taken by a
nation to promote its growth and protect itself from subversion, lawlessness, and insurgency. It
focuses on building viable institutions (political, economic, military, and social) that respond to
the needs of the society. Developmental programs, carefully planned, implemented, and
publicized, can serve the interests of population groups and deny exploitable issues to the
insurgents. Foreign Internal Defense (FID) is the participation by civilian and military agencies
of a government in any of the action programs taken by another government to free and protect
its society. Foreign Internal Defense is the US role in the IDAD strategy.
a. In countering an insurgency, the Army may employ specially trained forces or training
teams. This sort of activity may include the transfer of defense equipment, the training of
foreign soldiers, advisory assistance, or even the commitment of combat forces. All
military efforts in a counterinsurgency campaign will be made in concert with the HN
and the initiatives of other US government agencies involved to ensure a synchronized
national effort.
b. The forces selected for FID will depend on the threat to be countered. Special
operations forces, light and heavy forces, aviation units, logistical support, and a variety
of training teams may be used for counterinsurgency efforts.
c. The high degree of selection and training, provided it is done well, tends to minimize
battle fatigue casualties and misconduct stress behaviors. However, if units are hastily
selected and deployed, they are likely to have problems facing the special stressors in
operations other than war (listed in Table 9-1).
d. Refer to Table 9-3 for mental health considerations and recommendations in support of
counterinsurgency operations.
9-4. Combatting Terrorism
a. Terrorism and the threat of terrorism are widespread in the modern world. Terrorism
can occur throughout the operational continuum. It is defined as the unlawful use or
threatened use of force or violence against people or property to coerce or intimidate
governments or societies, often to achieve political, religious, or ideological objectives.
(1) Terrorists may be independent groups or may be supported covertly or openly
by hostile states. Terrorist organizations sometimes cooperate with each other in
pursuit of common strategic objectives.
(2) US Army doctrine calls for preventive action (antiterrorism) along with
reactive measures (counterterrorism) to meet the terrorist threat to US forces,
representatives, and agencies and to the security of American citizens and
property.
(a) Antiterrorism consists of those defensive measures used to reduce the
vulnerability of personnel, family members, facilities, and equipment to
terrorist acts.
(b) Counterterrorism is comprised of those offensive measures taken to
prevent, deter, and respond to terrorism. Terrorism must be dealt with in
the Army's daily operations as well as being of concern in war and
operations other than war. Terrorist tactics may be directed at service
families, recreational facilities, and general targets such as commercial
airliners.
Table 9-3. Stress Considerations andand Recommendations for Stress Control in
Counterinsurgency Operations
(c) Awareness of the threat and recognition that the indicators of terrorist
activity differ from those of the enemy on the conventional battlefield are
essential to combatting terrorism.
(d) Leaders at all levels must develop a broad view of this threat which
will guide them in securing their operations and in protecting their soldiers
from terrorists as well as from conventional enemy military forces.
(e) At the same time, they must not impose excessive anxiety, restrictions,
and repression which play into the enemies' game plan.
(3) United States counterterrorism forces must be protected against and treated for
combined effects offrustration, moral conflict, and boredom which are the
terrorists' main goals for success. When implementing preventive or reactive
programs, the following should be considered:

Battle fatigue is usually mild and can be managed in the units.



Special programs may be needed to prevent and treat alcohol and drug
misuse.
Additional programs may be required to prevent misconduct against
prisoners or noncombatants and other lapses of military discipline.
Soldiers who return from counterterrorism missions and other special
operations need a stand-down period. This should come before they are
reunited with their families or other noncombatants. The stand-down
period is needed to "defuse" the tension that has built up during the
operational phase. These programs are also needed to protect against
PTSD which may disable the soldier or veteran for several months or
years after returning home.
b. Terrorist acts produce debilitating stress reactions due to the shock of the event, the
sudden violation of familiar and safe settings, and the feeling of loss of control. The
stress may impact not only on the direct victims of the terrorist act but also on the passive
witnesses of the destruction, the immediate rescuers and care givers, and the more distant
care givers, friends, coworkers, and family. The following feelings or behaviors may
become evident:
o
o
o
o
o
o
o
o
Hostile feelings (repressed or expressed).
Feelings of dependence.
Feelings of powerlessness or incompetence.
Regressive behaviors (childish temper outbursts, stubbornness).
Negative responses to relocation and isolation.
Positive identification with the terrorists ("the Stockholm syndrome").
Sense of being a victim.
Negative feelings about one's own country or its allies.
c. Victims of disaster/hostage/terrorist situations suffer a high incidence of acute, chronic,
and delayed PTSD in addition to possible medical and surgical injuries. Treatment of
these disorders in the acute phase, and even better, preventive measures before symptoms
occur, can prevent the development of many chronic or delayed disabilities.
(1) Task-organized multidisciplinary stress control teams provide mental health
treatment services. These teams initiate preventive treatment measures to
individuals or groups involved in disasters, terrorist activities, and hostage
situations. Teams are task-organized depending upon the number of people
involved in the specific incident and the nature of the incident.
(2) The team assists victims, family members, witnesses, immediate rescuers, and
backup medical staff involved in terrorist or hostage situations. A variety of
individual and group techniques are used to help return persons to normal
functions and to reduce the impact of PTSD. Some examples of these techniques
are as follows:





Professional reassurance of the normality of acute stress reactions and the
positive expectation of rapid recovery and coping.
Critical event debriefing of groups. Everyone is encouraged to talk out
what happened and what everyone did (saw, heard, smelled, felt) in detail.
In the process, the group corrects misunderstandings and validates and
ventilates feelings.
Individual debriefing as needed.
Extremely limited use of fast-acting sedating medication in special cases.
Individual, group, or family follow-up as needed.
d. Refer to Table 9-4 for some operations other than war mental health recommendations
in support of combatting terrorism.
Table 9-4. Stress Considerations and Recommendations for Stress Control Issues -- Related to
Terrorist Attacks
9-5. Operations Other Than War (Peacetime Contingency Operations)
These operations are politically sensitive military activities. They are normally characterized by
the short-term, rapid projection or employment of forces in operations other than war. They are
often undertaken in crisis avoidance or crisis management situations requiring the use of military
instruments to enforce or support diplomatic initiatives.
a. Several Types of Operations. There are numerous types of operations which are
covered by this operational category. In each type of operation, different stress factors
will be present. Some operations, such as strikes and raids, inherently involve combat,
but are brief. Others, such as peacemaking and noncombatant evacuation operations, run
a high risk of violence but under much more ambiguous conditions. Military operations
other than war such as peacekeeping, nation building, and disaster relief should not lead
to combat, but do involve their own types of stressors. Soldiers are expected to be
ambassadors and representatives of the goodwill of the US, yet they may be separated
from home or family, sometimes abruptly. They may have to live under uncomfortable or
monotonous, boring conditions, perhaps for prolonged periods. In addition, they may be
exposed to an entirely different culture whose practices may seem alien, backward, or
even repulsive to those who do not understand the historical or practical reasons for them.
However, misconduct stress behaviors on the part of our troops can turn local goodwill
into enduring resentment and hatred. Table 9-5 provides some of the mental health
considerations which may be present in any given peacetime contingency situation and
recommended actions which may be taken. Each type of operation is presented below.
b. Attacks and Raids. The US conducts attacks and raids for specific purposes other than
gaining or holding terrain. Attacks and raids can support rescue and recovery operations.
They can destroy or seize equipment or facilities which significantly threaten national
security interests. They can also support counter-drug operations by destroying narcotics
production or temporary storage facilities used during shipment, or support HN's actions
in this regard. Depending on the intensity and duration of combat and on the success (or
lack of success), strikes and raids produce traditional combat stress behaviors. The level
of secrecy in which the operation is conducted can produce added stress for the soldier
and his family. Depending on the size and planned duration of the operation, mental
health/combat stress control personnel may accompany the strike force or remain at home
station. Mental health/combat stress control personnel should be involved as early as
feasible in planning and recovery.
c. Shows of Force and Demonstrations. These operations lend credibility to our nation's
promises and commitments. They increase our regional influence and demonstrate our
resolve to use military force as an instrument of national power. Further, the NCA may
order these operations to bolster and reassure friends and allies. Health service support
activities to include combat stress control follow the traditional role of providing support
to a combat force. Demonstrations may involve high anticipatory anxiety but usually do
not cause psychic trauma unless open combat, accidental deaths, or terrorist acts result
from them.
d. Rescue and Recovery Operations. Rescue and recovery operations are sophisticated
actions requiring precise execution, especially when conducted in a hostile environment.
These operations may be clandestine or overt. They may include the rescue of US troops
or friendly foreign nations, or the location, identification, and recovery of sensitive
equipment or items critical to US national security. The level of hostilities to be
encountered will vary with each specific mission. Mental health support may be required
by the individuals being rescued or the force employed. The level of security for the
operation may result in added stressors to those accomplishing the mission.
Table 9-5. Stress Considerations and Recommendations for Stress Control in Peacetime
Contingency Operations
e. Disaster Relief Operations. Disaster relief operations provide emergency assistance to
victims of natural and man-made disasters abroad. These operations are responses to
requests for immediate help and rehabilitation from foreign governments or international
agencies. Mental health support may be required for both victims of the disaster and the
military units and health professionals caring for them. The victims' plight may be truly
distressing and leave memories of many horrible sights, sounds, and smells for all
involved. Recent disasters within the US have also expanded the role of the military
(Active and Reserve Components) in domestic disaster relief. In some instances,
identification with the victims may even be stronger. For some units, their own families
may be involved in the disaster while they must remain on duty for the common good.
f. Noncombatant Evacuation Operations. Noncombatant evacuation operations are
conducted to relocate civilian noncombatants from locations in a foreign country. These
operations are normally conducted to evacuate US citizens whose lives are in danger;
however, they may also include the evacuation of HN or third country citizens. These
operations are of short duration. They consist of rapidly inserting a force, occupying an
objective, and making a planned withdrawal. The amount of force used is normally
limited to that required for self-defense and the defense of the operations. Mental health
support may be required for both the forces employed and the civilians being evacuated.
The need for mental health intervention will depend upon the level of hostilities and the
psychological trauma encountered. It also depends on the anticipated duration of the
operation and the recent experiences of those being evacuated. After-action debriefing at
the small unit level should be routine. All evacuees should receive large group stress
debriefing. Critical event debriefings can then be scheduled for such groups who need
them.
g. Operations to Restore Order ("Peacemaking''). These operations are intended to
establish and restore peace and order through the use of force. The US conducts these
operations when it is in its national interest. Intense efforts are made to stop a violent
conflict and to force a return to political and diplomatic methods of resolution. The US
typically undertakes "peacemaking" operations at the request of appropriate national
authorities in a foreign country. It may also conduct these operations to protect US
citizens as part of an international, multilateral, or unilateral operation. The threat of
armed resistance or attack by one or more disgruntled parties in the conflict is high. This
may take the form of overt battle, major terrorist attack, or covert harassment and
sniping. The rules of engagement may require not returning fire until fired upon, with the
source of hostile fire clearly identified. Combat stress control support for peacemaking
forces requires the traditional support to combat forces. Peacemaking forces must also be
prepared to counter added stressors. These stressors may include language and customs
barriers, ambiguous threats, and the lack of freedom of movement.
h. Peacekeeping Operations. Peacekeeping operations are military operations conducted
with the consent of the belligerent parties to a conflict. These operations are conducted to
maintain a negotiated truce and to facilitate a diplomatic resolution. The US may
participate in peacekeeping operations under the auspices of an international
organization, in cooperation with other countries, or unilaterally. Peacekeeping
operations support diplomatic efforts to achieve, restore, or maintain peace in areas of
potential or actual conflict. Units of peacekeeping forces may use force only in clear
cases of self-defense. Due to the nature of peacekeeping operations, misconduct stress
behaviors can result from a number of factors. Another characteristic of peacekeeping is
isolation of small units for prolonged periods with only radio or telephone contact with
their superiors. Also, any violence directed against the peacekeepers will likely come
from people whom they intend to be helping. Thus, a sense of betrayal aggravates the
stress inherent in the event. Table 9-6 provides mental health considerations and
recommendations in support of peacekeeping operations.
i. Humanitarian and Civic Assistance. US Army combat support/CSS units may be
deployed or rotated to friendly HNs to assist that country in developing its resources.
These activities serve the basic economic and social needs of the people of the country
concerned. They --
o
o
o
Support the civilian leadership.
Benefit a wide spectrum of the community.
Should be self-sustaining (once completed) or supportable by the HN civilian or
military agencies. Examples include - Providing medical, dental, and veterinary care in rural areas.
 Training local health care personnel in hygiene and preventive medicine.
 Assisting in establishing mental health and social service agencies.
 Performing engineer projects, such as building roads, bridges, and flood
control dams.
Army units engaged in humanitarian and civic assistance range from active Army units
deployed for relatively long periods to Reserve Component units on annual training.
These conditions can cause a wide variety of stressors related to acclimatization to the
environment and culture, coupled with separation from home.
9-6. Stress Problems of Military Operations Other Than War
The stress problems of military operations other than war are recognized by Army long-range
planners. The Army must develop an appreciation of low-key, frustrating, and frequently
unglorious work. This will not be easy for our soldiers from a culture noted for its impatience
and thirst for decisive outcomes. In some areas, we may have to "train down" to less
sophisticated equipment because operations other than war frequently are not appropriate for
displaying the latest technology. Finally, there is the matter of culture. The American sent to
function in an alien culture will have to possess some knowledge of that culture if he is to
successfully interact with and influence the members of that culture. For additional information
on operations other than war and peacetime contingency operations, refer to FMs 100-5 and 10020. For specific information on medical operations in this environment, refer to FM 8-42.
Table 9-6. Stress Considerations and Recommendations for Stress Control in Peacekeeping
Operations
CHAPTER 10
WAR AND THE INTEGRATED
(NUCLEAR, BIOLOGICAL AND
CHEMICAL) BATTLEFIELD
10-1. Introduction
War with sustained operations has the potential to generate numerous KIA, WIA, and battle
fatigue casualties. To counter this, all units must be well-trained and well-led, and all soldiers
made aware of the factors that cause battle fatigue (see Table 10-1). Active prevention programs
can reduce the incidence of battle fatigue casualties. Attrited units with exhausted leaders can
become incapable of self-help. These units must be permitted to reconstitute psychologically as
well as physically. Only then can they be a combat effective force prepared for return to the
battle. Battle in the rear area will increase stress and stress casualties in all units.
Table 10-1. Likely Stress-Producing Aspects of War on the High-Tech Battlefield
Table 10-1. Likely Stress-Producing Aspects of War on the High-Tech Battlefield (continued)
NOTE
At the end of the conflict, after-action debriefings should be conducted. These debriefings, in
small groups if possible, are conducted to help prevent PTSD. Post-traumatic stress disorder can
occur even in soldiers who showed no disability during combat.
10-2. The Battlefields of War
During war the battlefields are, by definition, chaotic, intense, and highly destructive. They may
extend across wider geographical areas. While each of these features can be understood
separately, their combined effects constitute the actual setting of operations.
a. Employment of Soviet-Type Offensive Doctrine. A characteristic of the offensive
doctrine developed by the former Soviet Union is continuous attack by echelons of fresh
units. Supported by massed artillery, these units reinforce success, bypass resistance, and
break through. All available means are employed, perhaps including NBC, to destroy and
disrupt rear area command, control, and logistics. Electronic warfare is another tactic;
this blocks communication and spreads misinformation. These tactics maximize
confusion, uncertainty, shock, and fatigue. They are intended to make the defender
unable to function -- to put him in a state of physiologic and mental helplessness. This
state was called battle paralysis or shock by the former Soviet Union.
b. Employment of Battlefield Tactics. United States Army operations doctrine intends to
minimize the effectiveness of potential enemy tactics and turn the tables on an aggressor.
Instead of waiting passively to be overrun or isolated, US units must take the initiative
and carry the attack to the enemy rear. They must disrupt the enemy's timetable and
damage some of his reserve echelons. They must deprive his remaining force of sleep and
confidence so they develop battle paralysis or desert their unit. Even with our
technological advantage, we must expect to fight around the clock, whether on defense or
offense. We must rest and resupply in a highly mobile environment. To succeed, our
leaders and troops at all levels must retain the mental agility to detect windows of
opportunity in the midst of confusion and stress. Leaders must act spontaneously and
synchronously in accordance with their commanders' intent, even though the situation has
changed and communications are disrupted. Exhausted and attrited units, even those
which have suffered mass casualties, must be returned quickly to the battle. The demands
on CSS units, as well as the combat arms, may be extreme. If NBC weapons are
employed, the stressors on the integrated battlefield will be incalculably greater.
c. Lines of Operation. In modern war, Army forces must prepare to fight campaigns of
considerable movement, not only to reduce vulnerability but also to obtain decisive
points. The speed with which today's forces can concentrate and the high volumes of
supporting fires they can bring to bear will make the intermingling of opposing forces
nearly inevitable. Telling friend from foe in darkness, smoke, and dust will be difficult.
NOTE
With the rapid pace and the urgency of firing first, tragic episodes of accidentally killing
friendly forces ("brother" killing "brother" or fratricide) may happen. Prevention requires
emphasis on vehicle and other identification training, awareness of the tactical situation,
and continual risk analysis by leaders at all echelons.
(1) From the first of battle, deep reconnaissance, air mobility, long-range fires,
and SOF will blur the distinction between front and rear. This will impose a
requirement for allaround defense and self-sufficiency on all units. Throughout
the battle area, attack and defense will often take place simultaneously as each
combatant attempts to mass, economize locally, and maneuver against his
opponent. This creates a state of uncertainty that calls for continued vigilance.
Constant vigilance is impossible for individuals to maintain. Only a well-trained,
highly-cohesive unit can maintain constant vigilance for a prolonged period of
time.
(2) Fluidity will also characterize operations in the rear of forward-deployed
committed forces. Guerrillas, enemy SOF, and terrorists will seek to avoid setpiece battles and to strike at scattered points of vulnerability. Defending forces
will try to preempt such attacks wherever they occur.
d. Lethal Systems. With the end of the cold war, sales of high-tech weapons (by the
successors to the former Soviet Union and by western countries) may increase rather than
decrease. The US intends to maintain our technologic advantage. Potential enemies,
however, may field high-quality weapons systems whose range and lethality equal or
exceed those of our lead elements. The following examples indicate a concentration of
enormous combat power, especially at decisive points. These may be used by potential
enemies, as well as by ourselves and our allies.
(1) Potent ground and air systems with missiles (air-to-surface, surface-to-surface,
and surface-to-air).
(2) Armored vehicles with reactive armor and all-weather, day-night target
acquisition systems.
(3) Multiple-launched rocket systems and tube artillery capable of saturating large
areas with fire at really long ranges.
(4) Fixed-wing aircraft and attack helicopters firing multiple bomblet munitions.
(5) Scatterable mines with delayed or smart fuses.
(6) Fuel-in-air explosives which approach the blast effects of low-yield nuclear
weapons.
(7) Precision-guided or smart fire and forget munitions.
(8) Nonpersistent or persistent chemical or biological agents, or nuclear warheads.
e. Sensors and Communications. Wide-ranging surveillance, target acquisition sensors,
and communications will provide information almost immediately. These will increase
the range and scope of battle. Sensors offer the commander more than just timely
information on deep enemy locations and activity. They also serve as the basis for
attacking enemy follow-on forces or units resting or reconstituting in reserve. Since these
attacks can be of vital importance in battle, the sensors and communications means which
make them possible are particularly valuable and subject to counterattack. They will also
be subjected to electronic countermeasures and deceptive simulation devices which
decrease the validity of their input.
NOTE
When functioning, battlefield sensors may contribute to information overload. If too
much reliance is placed in them, confusion, stupor, and even panic may occur when they
malfunction or are deceived, as they surely will be at times.
Caution should be taken with global position locating devices. These provide tremendous
technologic advantage, but troops must not become so dependent on them that they
cannot navigate by map and compass when the device is damaged.
f. Command and Control. The more fluid the battlefield, the more important and difficult
it will be to identify decisive points and focus combat power. Under such conditions, it is
imperative that the commander's intent and concept of operations be understood
throughout the force. Communications will be interrupted by enemy action at critical
times. Units will have to fight while out of contact with higher headquarters and adjacent
units. Subordinate leaders must be expected to act on their own initiative within the
framework of the commander's intent. If soldiers at all levels are trained to be active
rather than passive, that in itself will substantially counteract the tendency to become
battle fatigue casualties. However, the necessary mental functions are also the functions
more likely to deteriorate with sleep loss, fatigue, and stress.
g. Air Dimension. The airspace of a theater is as important a dimension of ground
operations as the terrain itself. Airspace is used for maneuver, delivery of fires,
reconnaissance and surveillance, transportation, resupply, insertion of forces, patient
evacuation, and command and control. The control and use of the air will always affect
operations and can decide the outcome of campaigns and battles. Commanders must
distribute proportionally air power in planning and supporting their operations. They
must protect their own forces from observation, attack, and interdiction by the enemy and
must expect the enemy to contest the use of the airspace.
NOTE
· Having air superiority decreases battle fatigue casualties.
· Being subject to air attack increases battle fatigue casualties.
· Being hit by friendly air attack greatly increases battle fatigue casualties.
On the rapidly changing, integrated battlefield, fast-moving friendly aircraft (who are
themselves at great risk from air defenses) will have only a split second to distinguish
friendly units from enemy targets.
10-3. The Integrated (Nuclear, Biological, and Chemical) Battlefield
a. The Nuclear, Biological, arid Chemical Warfare Threat. The future battlefield may
have a high threat of NBC. Until recently, the former Soviet Union continued to test,
produce, and stockpile NBC weapons. Soviet doctrine, organization, training, and
equipment supported NBC weapons' use, especially chemical, in order to obtain a
military advantage. Former Soviet weapons or design experts may be acquired by Third
World countries. Other countries, notably Iraq, have recently used chemical weapons in
combat. Use of NBC weapons in rear areas may severely degrade CSS capabilities. Its
use would increase casualties and patient work loads, slow operations, and rapidly fatigue
personnel because they are forced to operate at the various MOPP levels for extended
periods of time. Evacuation and triage will be complicated by contaminated casualties.
Vehicles and aircraft will require decontamination at the completion of all missions that
encountered contamination from a NBC agent.
b. Nuclear Warfare. Even though the primary purpose of nuclear weapons is to deter their
use by others, the threat of nuclear escalation hangs over any military operation involving
the armies of nuclear powers. It imposes limitations on the scope and objectives even of
conventional operations. United States nuclear weapons may be used only by following
specific directives from the NCA after appropriate consultation with allies. Even if such
authority is granted, however, the employment of nuclear weapons would be guided more
by political and strategic objectives than by the tactical effect. A particular authorized
employment of nuclear weapons would certainly magnify the destructiveness of
operations and could sharply alter their tempo. Besides the effects of physical damage,
the psychological stress on soldiers would be severe, especially if they have not been
prepared by their leaders. As a consequence, battles and campaigns may last only hours
instead of days or weeks, crippling friendly and enemy combatants.
(1) During the Cold War, a full scale global exchange of all available
thermonuclear weapons was widely believed to be capable of making the earth's
environment temporarily unsuited to human civilization. This doom was
attributed to persistent radiation and to the dust particles which would be lifted
into the upper atmosphere, causing temporary climatic changes and cooling of the
earth ("nuclear winter"). More accurate computer models suggest only a partial
"nuclear autumn" is likely, but disruption of crops, distribution means, and
technologic infrastructure would still cause extreme global suffering.
(2) During the Cold War, many people were convinced that first use of any
nuclear weapon in war would inevitably bring on an uncontrollable rapid
escalation. The "nuclear winter scenario," however, clearly is not triggered by a
small number of low-yield tactical nuclear weapons. Climatic changes were not
encountered following the fire-bombing of cities in WWII or the occasional
atmospheric testing of large thermonuclear weapons by several of the nuclear
powers. The breakup of the Soviet Union and the continued progress in strategic
arms limitations makes massive global strikes unlikely now, but the future
remains uncertain. Fear of radioactive fallout spreading to other regions of the
globe could be created even by a regional nuclear conflict.
(3) Given this background, if US troops know a nuclear weapon has been used but
are not being kept adequately briefed by their leaders, some may still think we are
on the brink of total world catastrophe and perhaps already over the edge. The
spread of rumor will be compounded by the usual problems of communication in
the presence of electronic jamming, deliberate misinformation by the enemy, and
conventional countermeasures. It may be further disrupted by the electromagnetic
pulse of high-altitude nuclear bursts.
(4) Measures must be taken in advance to structure and prepare the soldiers'
perceptions of the situation. If this is not done, there is potential for hopelessness.
In the common Cold War perception of nuclear war, there was no winner, and
even if you survived the initial blast, there is no hope of meaningful survival. It is
unknown what such a level of hopelessness for the future of humankind would do
to inadequately-trained soldiers. Some soldiers have been exposed to movies,
books, and TV shows which have created myths and gross exaggerations about
the effects of radiation.
(5) We must prepare soldiers mentally and emotionally for the shock of seeing or
hearing a first nuclear attack. An important step is to provide realistic, clearly
presented information on the risk of various levels of radiation exposure.
Information about true risks, especially low-levels of radiation, should be
compared to those risks associated with other commonly accepted hazards. These
hazards may include cigarette smoking, therapeutic x-rays, and high altitude
flying or residence.
(6) Nuclear weapons use usually implies high-intensity conflict. The possibility of
terrorist use (or of attacks on civilian reactors or damage to nuclear-armed
weapons in conventional war) must also be considered. United States' forces
might be called in as part of a peacekeeping force following use of nuclear
weapons. This could be in a conflict between Third World countries or between
factions in a civil war within a nuclear power. They might also be called in to
support civil authorities following a major nuclear reactor accident. Actions to
prepare soldiers for the special stressors of nuclear war are discussed in Appendix
A.
c. Biological Warfare. The US has renounced the use of biological weapons. However,
this unilateral renunciation does not free our own forces from the threat of enemy
biological warfare. Army forces must continue to train to fight an enemy who could use
biological weapons. New genetic technology may put this capability into the hands of
unstable Third World countries (or terrorists) as they develop a pharmaceutical industry.
Biological warfare is, therefore, a threat in war and operations other than war (conflicts).
(1) An added stress feature is that it may be difficult to prove that the presence of
biological agents is an act of war rather than a natural or accidental occurrence.
Reputable biologists still argue that the mycotoxins ("yellow rain") which killed
Laotians and Cambodians were not a Soviet (North Vietnamese) weapon but only
naturally fermented bee feces (although interestingly, the deaths apparently
ceased after the allegations reached the world press coverage). Such weapons
could also be used as agents of economic/agricultural sabotage without war being
declared. Some of those agents cause long-term contamination of ground and
water.
(2) Biological toxins pose a threat similar to chemicals but perhaps harder to
defend against. Some toxins, such as the ergot derivatives, produce organic
psychotic states. Others, like the mycotoxins, are terror weapons which produce a
rapid, horrible death by uncontrollable bleeding.
(3) Infectious organisms create the added hazard (and psychological threat) of
contagion and uncontrolled spread. The success of medical science in controlling
the rapidly lethal epidemics of history may make the populace less familiar with
how to face this risk. Hence, this unfamiliarity makes the populace more
susceptible to panic or maladaptive reactions if newly created threat agents spread
more rapidly than defenses can be fielded,
d. Chemical Warfare. Chemical warfare was employed in KIWI and sporadically since
throughout this century. Use of chemical weapons is most likely at the high and low ends
of the combat continuum -- in high-tech war, or against insurgents or minority groups in
remote areas. United States' forces maintain a capability in this area only for deterrence.
Chemical warfare presents some of the same complications as nuclear operations,
although chemical agents are easier to defend against.
(1) Because chemical weapons are more widespread and the inhibition against
their use is lower for some nations, US forces are more likely to face a chemical
than a nuclear threat, Chemical weapons are inexpensive and can be produced by
Third World countries which have factories that produce fertilizers, insecticides,
or pharmaceuticals.
(2) Chemical agents can be lethal and devastating against those who lack adequate
protection or training. Nerve agents in sufficient concentration kill within minutes
with convulsive seizures. Blister agents rarely kill; rather they are employed as
casualty-producing agents. Blister agents like lewisite and mustard can cause
either immediate or delayed eye and skin pain, blister formation, and with severe
exposure, lung and bone marrow damage. Choking agents cause the lungs to fill
with fluid -- "drowning on dry land." The potential for mass casualties is great
among unprotected troops and civilians. The nature of their deaths, while not
more horrible than that from flame, blast, or projectile weapons, has an element of
mystery. This may be especially unnerving to those who witness it or come on the
scene later.
(3) For troops with adequate protective equipment, chemical agents serve
primarily as a harassment which makes other combat and CSS operations much
more difficult and time consuming. They also produce high rates of battle fatigue
casualties (most of whom return to duty if properly treated) and sublethal
chemical injuries (many of which may have longterm disability).
e. Stress Reaction to the Nuclear, Biological, and Chemical Warfare Threat. The threat
of chemical-biological use will require frequent high levels of MOPP. Using protective
clothing and other defensive measures against NBC warfare adds to physical fatigue?
primarily because of heat, visual and auditory restriction, and impeded movement, The
necessity for precautions will further reduce the time available for rest and sleep,
increasing exhaustion. The threat of NBC warfare is a major source of stress whether or
not NBC agents are actually used. The associated fear of the unknown, the high degree of
ambiguity in detecting the threat, and the uncertain short- and long-term effects of NBC
weapons add significant psychological stress to the physical/physiologic stress of MOPP.
Stress itself contributes greatly to fatigue.
(1) Overreactions. Many soldiers may overreact to an NBC threat -- that is, do
more than the situation calls for. The reactions listed below were seen in WWI
(when chemical weapons were used) and sometimes in WWII (although chemical
weapons were not used). They have been seen in peacetime civilian populations,
in response to the news about the Three-Mile Island and Chernobyl nuclear
reactor accidents, chemical spills, dioxin and toxic chemical waste dumps, and
AIDS. Overreactions to NBC are discussed in the following paragraphs.
(a) Increased sick call (hypochondriasis). People will overattend to
physical sensations, looking for warning signs. They will find things that
worry them and will bring them to the doctor or medic for reassurance or
in hope of being sent to safety.
(b) Increased "conventional" battle fatigue. Uncertainty, lack of
confidence in equipment and leaders, assuming a passive defensive
posture, and new or surprise weapons all tend to increase battle fatigue
symptoms of anxiety, depression, or simple exhaustion.
(c) Nuclear, biological, and chemical battle fatigue. This is battle fatigue
with physical symptoms that mimic real NBC injury. The early US Army
WWI ratio (in supposedly well-trained but inexperienced troops) was two
"gas mania" cases for every one true exposure case (a 2:1 ratio). Epidemic
hysteria can occur as the first anxious person hyperventilates (breathes too
fast, gets light-headed, and has "pins and needles" sensations and muscle
tenseness in face, fingers, and toes). Others, seeing this and believing him
to be a true gas casualty, become anxious and hyperventilate, too.
(d) Malingering. Nuclear, biological, and chemical battle fatigue is, by
definition, not a voluntary behavior. Soldiers who deliberately fake NBC
injury, or who self-inflict minor chemical injuries to gain evacuation are
malingering, a misconduct stress behavior. Exposing one's radiation
counter to radiation artificially in order to raise the count and be relieved
of duty also is malingering.
(e) Panic flight. This may also be epidemic. It occurs when a group feels
threatened, unprepared, and believes that the only defense is immediate
flight. Some event causes one soldier to run, after which the others in the
group panic and run wildly.
(f) Rumor. The former Soviet Union, through their military literature,
recognized and valued the threat of NBC warfare to "demoralize through
rumor." These rumors were concerned with family and home, as well as
with self and unit, in any perceived NBC war. Commanders must counsel
the spreaders of rumor and ensure that the best available information
passes through the chain of command and reaches every soldier. Covering
up or withholding information can permanently destroy the leadership's
credibility. Utilization of unit or attached public affairs personnel and a
solid Command Information Program (CIP) can prevent rumors or stop
them from spreading. A wide range of CIP products are available through
public affairs channels. Commanders should avail themselves of these.
(g) Excessive anxiety and "phobic" avoidance. Soldiers may refuse to go
into places or to use equipment which is wrongly believed to be
contaminated. Even when they go, they may be too anxious and cautious
to perform well. They may shun people who are believed to be contagious
or contaminated.
(h) Excessive decontamination ("obsessive-compulsive" cleaning). This
wastes time and scarce supplies. This can even cause dermatologic
problems if soldiers use caustic decontamination chemicals on their skin.
(i) Congregating in safe areas. People will naturally find excuses to stay
in collective protection or safe areas. Headquarters personnel in such
protection areas may get out of touch with the troops in the field. Medical
teams which must work in collective protection areas may find many
nonpatients giving reasons to join those who are working inside and being
difficult to move out. The misconduct stress behavior version of this is
desertion to hide in safe areas.
(j) Stealing protective equipment. If there is not enough protective
equipment or collective protection to go around, another potential
misconduct stress behavior is stealing from or killing others to take over
their protection.
(k) Suspiciousness. Vision and hearing are impaired in MOPP and
everyone looks alike. Even friends may not be readily identified. People
tend to develop a "paranoid" suspicion of the strange, monster-like
figures; they may become jumpy and shoot at shapes or sounds without
checking first. This requires emphasis on vehicle and other target
identification training, challenge procedures, and passwords. Identifying
labels may have to be added to personalize the MOPP gear.
(l) Risks to leaders. Mission-oriented protective posture requires much
more active leadership. It hides the usual nonverbal cues of alertness,
understanding, and readiness to act which leaders normally rely on.
Leaders must move around, touch to get attention, and insist on
information and confirmation. This movement increases the leader's risk
of heat exhaustion, carelessness, and being accidentally shot by a jumpy
soldiers. Accidental fratricide (killing of leaders and other friendly
personnel) has been alarmingly high in MOPP field exercises which use
the multiple integrated laser engagement simulation devices. The same
problem occurs in jungle and night fighting where vision and hearing are
also reduced. Fratricide must be prevented by careful adherence to the
TSOP, coordination between units, target identification, and the use of
challenge procedures.
(m) Isolation and loss of cohesion. Mission-oriented protective postures
interfere with normal friendly support, such as conversation, sharing
snacks, or simply smiling. As a result of the sensory and social isolation
and encapsulation, soldiers tend to feel alone. They may feel surrounded
by a totally hostile world in which even the air they breathe is against
them. This isolation tends to make people become passive, insecure, and at
high risk for battle fatigue unless it is actively counteracted. It requires a
more active, verbal, and deliberate effort to maintain a sense of
comradeship and unit cohesion.
(2) Underreactions. Underreactions may be more likely than overreactions in
some situations.
(a) Denial. Things are too horrible for a soldier to think about, so he just
thinks about something else.
(b) Rationalization. "No one would be so crazy as to use such terrible
weapons, so why should we waste our time preparing and training for
them?"
(c) Fatalism. "If anyone is so crazy as to use these weapons, they are so
terrible that I can't protect myself anyway, so why bother to prepare, and
train?"
(d) False alarm. If there is a threat situation with frequent false alarms,
troops may neglect alerts and fail to react, believing it "just another false
alarm" when, in fact, it is the real thing.
(e) Overconfidence. "We have this one defense (or detector, or higher
headquarters, or whatever) that's going to warn and protect us. We can
forget about everything else."
(f) "Pie in the sky." "The Strategic Defense Initiative, or immunization, or
something will solve all these problems within the next year, so why train
now?"
(g) Intellectualization. "This is so serious that we have to study it and do
more research before we take any action to correct the problem."
(3) Consequences of the maladaptive responses. Any of these maladaptive
responses lowers the maximum advantage that protective equipment and training
can provide during accomplishment of the mission. Underreactions may lead to
discarding equipment and failure to follow the TSOP. Overreactions tend to
disrupt a unit's overall ability to perform its mission. Appendix A presents
recommendations for how leaders can prevent or correct these maladaptive
reactions to the NBC threat.
CHAPTER 11
PREVENTION OF BATTLE FATIGUE
CASUALTIES AND MISCONDUCT
STRESS BEHAVIORS
11-1. Introduction
In combat, battle fatigue is inevitable but high battle fatigue casualty rates are not. History shows
that highly trained and cohesive units with good leadership have had fewer than one such
casualty for every ten WIA, even in intensely heavy fighting. This is significantly fewer than the
usual one per four or five in moderate intensity battle and one per two or three in intense
fighting. By knowing what factors in the tactical and overall situation increase battle fatigue,
leaders and unit members can take action to counteract those factors. They must share the
burden, resolve internal conflicts, build unit cohesion, and reduce stress. The same measures,
plus positive adherence to discipline and the Law of Land Warfare, also prevent misconduct
stress behaviors which could defeat the purpose of the mission. We can overcome the stressors of
the battlefield -

Through tough, realistic training which builds confidence.
By looking out for each other.
11-2. Leader's Role in Training Battle Fatigue Prevention
a. History shows what kinds of situations and stressors tend to produce battle fatigue
casualties. Some are conditions which can be modified or controlled by good leadership.
Other situations or events may be beyond the leader's control; however, knowing which
situations or events increase stress and battle fatigue enables the leader to compensate by
reducing other stressors and taking corrective actions. The leader must also plan for the
care of battle fatigue casualties and still accomplish the mission.
b. Mental health/combat stress control personnel have the mission to give formal training
and consultation on how to reduce stressors. This training and consultation is provided to
both medical and line officers, NCOs, chaplains, and troops.
c. Appendix E elaborates on material which is part of the Advanced NCO Course and
Advanced Officer Course core curricula. The same material is also outlined in GTAs 213-4, -5, and -6. These GTAs are designed to facilitate "hip pocket training" in the field.
They are camouflaged pocket cards which should be available through all Army Training
and Audiovisual Support Centers. The GTAs can serve as training aids in peacetime and
as reminders and checklists in war.
11-3. What the Members of the Unit Can Do to Control Stress
a. Unit leaders and members can control stress by assisting one another. They need to be
able to recognize stress in each other. One important way in which stress can be
alleviated is by talking things out ("ventilation"). This requires encouragement and
listening to the soldier under stress. Realistic reassurance is helpful. Arguing with the
soldier and being critical or disparaging usually is not helpful. Ways which unit leaders
and members can assist one another in controlling stress may include -o
o
o
o
o
All soldiers being assigned or developing "battle buddies" with whom they share
their feelings and ventilate about their experiences.
Officers and NCOs in the same unit encouraging each other to talk things out
together, especially those issues or feelings they cannot share with their troops.
Officers and NCOs in sister units providing ventilation for each other.
Officers and senior NCOs in the chain of command, chain of support, and staff
positions encouraging junior leaders to talk freely about their feelings at suitable
times and places without fear of reprisal. Formal after-action debriefings of the
unit leaders after difficult actions are one example of suitable times. Another
example is during change of command transition workshops.
The unit chaplain being someone that anyone can ventilate to about anything.
b. Should a unit member be in a crisis, a number of actions may be useful. These actions
are to -o
o
o
Observe and attempt to calm the soldier.
Protect him from danger (restrain only if necessary).
Ensure that someone takes charge of the situation, finds out what is going on, and
takes appropriate action. Specific actions which should be taken by a buddy or
junior leader are outlined in GTA 21-3-4 and -5.
11-4. What the Individual Can Do to Control Combat Stress
a. Individuals must drink enough fluids, eat enough food, and attempt to get rest/ sleep as
often as possible.
b. Everyone should learn at least two relaxation techniques (and preferably more) that can
be used at times when physical exercise is not feasible.
o
o
One technique should provide quick reduction of excessive alertness without
taking the mind, eyes, or hands off the task.
A second technique should provide deep relaxation for refreshing sleep even
under high-stress situations.
c. Care must be taken to use relaxation techniques only at tactically appropriate times.
Mental health personnel can assist in teaching these methods. Useful techniques which
can be used alone or in combination include --
o
o
o
Visual imaging self-relaxation. Imagine yourself in a relaxing situation. Pick your
own relaxing situation, then imagine it with every sense of your body -- colors,
shapes, textures, sounds, smells, temperature, and touch of it.
Brief or progressive muscular relaxation. Tense your muscles for a few seconds
(approximately 5-10) and then slowly release this tension while feeling the warm
and heavy sensation that occurs when you relax. Either tense all your muscles at
once or start with the muscles in your toes and work slowly up the muscles in the
rest of your body.
Stretching. Stretch your muscles and joints, move them around, and shake out the
tension.
CAUTION
When the soldier must stay alert and be responsive to the environment, special
relaxation techniques can be used that will not disrupt performance. In such
situations, deep relaxation techniques would be tactically inappropriate and unsafe.
o
o
o
Positive self-talk. Say to yourself, "Easy does it," "Take your time," "I can do it,"
"OK, go for it!" or any other brief words of encouragement.
Abdominal breathing. Breathe slowly and deeply, using the abdominal muscles
(not the chest muscles) to move the air in and out. Even one slow breath in which
you breathe in, hold for 2-3 seconds, and then exhale slowly (about 5 seconds)
can steady the nerves and refocus attention.
Breathing meditation. Focus your attention on your breathing, especially each
time you breathe out. Say the same word or short phrase once each time you
exhale (such as the word "one" or "relax"), over and over, while passively letting
all other thoughts drift out of your mind.
d. Individuals should share feelings constructively ("ventilation").
e. Individuals can also reduce stress by planning ahead, preparing for the mission, and
ensuring readiness. The best way to alleviate stress is to take appropriate action. The
above techniques should be practiced frequently until they become automatic.
11-5. Prevention of Misconduct Stress Behaviors
The measures which reduce battle fatigue and prevent battle fatigue casualties should also help
reduce the incidence of misconduct stress behaviors. However, additional actions also need to be
practiced consistently by leadership at all echelons and by buddies at the small unit level.
a. Clearly state and teach the Standards of Conduct. United States forces will faithfully
adhere to the Law of Land Warfare and the UCMJ.
b. Reemphasize those standards repeatedly, especially every time they are violated by the
enemy or at the first early signs of slippage by our troops. Some of the early signs may
include talking about breaking the law, stretching the interpretation, or committing acts in
the "gray" areas which cannot be documented for legal action. Let troops express
(ventilate) their frustrations verbally among themselves, but not in action.
c. Emphasize national, Army, and unit pride in living by the standard even under
provocative conditions. "We are American soldiers of the (unit). I know how you feel,
but we do not do that stuff. Those who do have let us down and are no longer part of us."
d. Explain, as often as necessary, the ethical, legal, practical, and tactical reasons why we
obey the rules. For example, "Provoking us to commit atrocities is exactly what the
enemy is trying to do to achieve his objectives, not ours." Restate the mission and its
objectives clearly.
e. Clearly state and consistently enforce the rules and regulations against substance abuse,
fraternization, and misconduct. Develop a group sense of "family" that makes such
improper behavior morally and spiritually unacceptable as well as illegal and punishable.
f. Set the personal example of correct conduct.
g. Report all violations.
h. Prosecute all verifiable violations.
i. Consistently and fairly punish misconduct and violation of the UCMJ in peacetime to
set the standard that misbehavior will not be tolerated.
APPENDIX A
LEADER ACTIONS TO OFFSET BATTLE
FATIGUE RISK FACTORS
This appendix provides recommendations for how leaders can control situations or events that
cause battle fatigue. Table A-1 summarizes the risk factors that are discussed.
Table A-1. Summary (Risk Factors)
Table A-1. Summary (Risk Factors)(Continued)
Table A-1. Summary (Risk Factors)(Continued)
A-1. Home Front
a. Risk Factor: Problems and uncertainties on the home front.
(1) Worrying about what is happening back home distracts soldiers from focusing
their psychological defenses on the combat stressors. It creates internal conflict
over performing their combat duty and perhaps not surviving to resolve the
uncertainties at home. An Israeli Defense Force study conducted after the 1973
Yom Kippur War found concerns about the home front to be the strongest
predictive factor which distinguished between soldiers who became "battle shock"
casualties and those who were decorated for heroic acts.
(2) The home front problem may be a negative one -- marital or financial
problems, illness, uncertain job security (if a reservist); or it may be something
positive -- newly married, new baby. All soldiers face greater potential problems
and uncertainties with personal matters if the military conflict is not popular at
home.
b. Leader Actions: Stabilize the home front.
(1) Help families develop unit identity and a support system.






Involve the soldiers' families in unit social activities. Teach them about the
unit's mission and history and include them in the sense of unit cohesion.
Know soldiers' personal backgrounds as well as their military skills. Keep
notes to remember details about each soldier's spouse, children, parents,
and outside interests which you can learn.
Help soldiers and their families to use Army and civilian support services
such as Army Community Service, Army Emergency Relief, post
morale/welfare/recreation activities, and the Red Cross.
Encourage soldiers and their families to draw moral support and assistance
from the unit and its members.
Use the unit or post chaplains and mental health team as valuable
resources. Get to know them personally, and encourage soldiers and
families to talk with them when they can help. Make command referrals to
mental health when necessary.
Promote and support a unit family or spouse network (family support
group) which communicates information and provides emotional support
and guidance for practical assistance to every unit family. Include those
who live far from the unit's military post on the mail-out roster for
disseminating information about the unit.
(2) Reduce problems of rapid mobilization and deployment for Active Component
and Reserve Component soldiers. This turmoil must be reduced by prior planning
which has been communicated to and practiced with the family. Help soldiers
prepare themselves and their families for the disruption and stress of a rapid
deployment.





Establish a system which keeps family members informed about the
progress of the deployment and the health and safety of their spouses,
consistent with realistic security restrictions.
Encourage family members to participate in family action plan or
community action plan conferences.
Encourage commanders to conduct periodic feedback sessions for
families.
Assure rapid humane casualty reporting to families and provide assistance
to them.
Involve families in organizing the unit's welcome home party.
(3) Prepare families in the theater of operations for the NEO plan. Soldiers will
have great emotional stress moving out to their combat positions and keeping
their minds focused on their missions if they are not confident that someone they
trust is looking after their families in the best way the situation allows. Failure to
provide that reassurance runs a high risk of battle fatigue casualties and of
misconduct stress behaviors such as going AWOL to stay with the families.

Have a credible NEO plan; talk about it and practice it.


Have a credible contingency plan for what will be done if the NEO plan
cannot be implemented because of political or operational reasons. Talk
about that frankly, and practice the contingency plan, too. Someone who is
known and trusted must be left in charge of those families.
Make clear to the soldiers that the best way they can protect their families
is by doing their combat duty.
A-2. New Soldier
a. Risk Factor: Soldier is new in the unit.
(1) The new soldier has not yet established trust and cohesion with buddies and
leaders. The Israeli study, discussed above, found this to be the second strongest
predictor distinguishing battle shock casualties from decorated heroes.
(2) New replacements who have no prior combat experience are at special risk
because not only are they facing extreme stress for the first time, but also the
veteran soldiers have little basis on which to trust them. Veteran soldiers who are
coming to a new unit after recovering from a wound or as survivors from other
units are also at risk. These veterans may adapt quicker than the new
replacements, provided they do not have internal conflicts and too much
unresolved battle fatigue.
(3) Soldiers who have been given increased/new job responsibilities, such as just
being promoted to NCO, are at risk. These soldiers may also be under special
stress for a while as they adjust to no longer being "one of the old gang" and
develop new horizontal bonding with other NCOs.
(4) Building unit cohesion is extremely important. The most important motive
which keeps soldiers doing their duty in combat is personal bonding. Personal
bonding is the personal trust and loyalty among members of a small unit. This
bonding makes them prefer to stick together in exceedingly stressful situations,
even when great hardship and danger are present.


The leader needs to encourage as much unit cohesion as possible. (See FM
22-100.) The leader ensures that the personal bonding is strengthened by a
sense of the unit's military identity (esprit) and its mission.
This combination of unit esprit and personal bonding makes "unit
cohesion."
 Unit esprit is like concrete; it keep its shape, but shatters easily.
 Personal bonding alone is like steel wire mesh; it is hard to break
but easy to bend.
 Combining the two produces a result that is far stronger than the
sum of its parts. Unit cohesion is like reinforced concrete. It
neither bends nor breaks.

Working together to overcome danger and survive is, in itself, a good way
to produce fast cohesion. But there are two disadvantages in waiting until
the danger is close before starting to develop unit cohesion.
 First, there is the big risk that the danger and stress will break up
the insufficiently cohesive team and roll over it. Everyone will
simply get killed or develop total battle fatigue.
 Second, it is possible to develop personally cohesive groups who
care only about their own comfort and survival and not about the
mission.
b. Leader Actions: Promote unit cohesion.
(1) Ensure that new arrivals are welcomed into the group and become known and
trusted members quickly.






In-brief the soldier explaining what the standards are and tell him how the
unit has performed in terms of meeting its own standards.
Appoint a suitable sponsor for each newcomer and monitor to see that the
sponsor shows the newcomer around and assists him in settling in on the
job and in the community.
Introduce new personnel (formally or informally) to all unit members.
Link the new soldier with an appropriate buddy or buddies in the combat
zone. This is essential for proper orientation.
Give newcomers time, if possible, to develop combat attitudes, skills, and
cohesion over several days before putting them into extremely stressful or
critical situations.
Conduct formidable, meaningful combat training whenever possible,
involving both the new and the veteran soldiers together.
(2) Impart unit pride and identity.




Educate the soldiers regarding the history of the small unit, its parent
units, the branch of service, and the Army.
Tell stories which honor and illustrate historical examples of soldiers and
units (as much like yours as possible) who showed initiative, endurance
and resilience, who bounced back from defeat, who overcame heavy odds,
or whose self-sacrifice led to eventual triumph of the higher cause
("Remember the Alamo!"). Do not just tell about easy military or small
unit successes.
Establish training criteria which will challenge each soldier or each
member of a team, squad, platoon, and company. These criteria should be
recognized as significant common challenges that all must pass.
Use distinctive unit symbols, tokens, and awards (such as patches,
plaques, and coins) which must be earned. Informal citations and
distinctions can also be extremely meaningful.
(3) Keep members of the same small teams always working together with their
leader.





Assign details and projects to a team, and let its leader organize how they
will be done.
Send a group, small teams, or at least buddy pairs if there is an opportunity
for R&R. Do not send a collection of individuals who will not work
together in the future.
Use equipment drills, physical fitness exercises, and team sports to
promote mutual reliance and closeness within each team and positive
competition and respect among all teams. These activities let off steam,
prevent boredom, and help integrate new replacements during times of
low mission activity.
Praise and reward teams, as well as the individual members, for their
performance.
Use team-building techniques -- have team members set team goals.
Conduct team rap sessions to talk about what is going well and not so well
in the group. Encourage open, honest communication.
(4) Encourage unit-centered social interaction outside duty hours. Monitor these
activities to -


Prevent drug or alcohol abuse (which tense soldiers may want to use to
"unwind").
Prevent fraternization (within the chain of supervision; between officers,
NCOs, and enlisted; between persons who are married to others, and so
forth).
Discourage cliques or interest groups which exclude or pick on other unit
members.
(5) Bring the whole unit together, when the situation permits.


Conduct formations, meals, award ceremonies, and other formal or
informal occasions which let the teams (squads, platoons, and/or
companies) get to know the members of the other teams.
Conduct activities which let individuals see the whole unit working
together.
c. Leader Actions: Conduct small team after-action debriefings after every difficult action
(in training and in combat). An after-action debriefing is an extension of after-action
reviews which are routine in training. Reconstruct what really happened so that the team
benefits from the lessons learned. At the same time, this releases bottled-up emotions and
inner conflict that can lead to decreased unit cohesion, battle fatigue, and perhaps even to
PTSD. This is the purpose of the after-action debriefing. Feelings of anger and mistrust
may go away on their own once the soldier sees how things looked to the others. At least
the feelings are out in the open and can be dealt with honestly. Soldiers' natural emotions
of loss and grief come out, too, when buddies are wounded or killed in combat. Guilt or
shame may come out when soldiers make mistakes. Such soldiers can be comforted and
helped to put things into perspective by the rest of the team. The mistakes can be
acknowledged and forgiven or atoned for. When conducting the after-action debriefing,
the leader must -(1) Select a location that is relatively safe from enemy attack.
(a) Ensure the location has adequate comfort and enough light to see
everyone.
(b) Bring the team (squad, crew, and/or section) together when the
situation permits and while the events are still fresh in their minds.
(c) Include only those personnel who took part in the action.
NOTE
Exceptions for permitting others may include unit members or new
replacements who just missed the action. Also, personnel that the team
trusts, such as the medic or the chaplain, may be included.
(2) Set the ground rules.
(a) State that the purpose of the after-action debriefing is not to find fault
or fix blame. The purpose is to share the experience as a team, to
strengthen the team, and to talk and learn together how to do better.
(b) Allow all ranks to freely express their observations and opinions
openly and honestly without fear of ridicule or reprisal from their peers or
leaders. No verbal abuse or fighting is allowed.
(c) Ensure all personnel agree that personal information, feelings, and
reactions which others share within the session will be privileged
information and not be talked about outside the group with anyone.
(d) State that operational lessons learned or system problems which the
debriefing identifies will be shared with other units or up the chain of
command or the NCO chain of support. Such lessons and issues will be
worded in terms that do not identify the specific team, unit, and
individuals involved.
NOTE
Make clear that these ground rules do not exempt the leaders and soldiers
in the team from upholding and defending the UCMJ and the Law of Land
Warfare.
(e) Ensure personnel know their rights if the event being debriefed
involved potentially illegal acts or misconduct stress behavior. Each
individual, and the team as a whole, has an obligation to do the right thing;
however, their individual rights must be protected. The team may wish to
involve a chaplain or legal counsel in the debriefing or in a subsequent
group session.
(3) Reconstruct the action from everyone's memories.
(a) Start just before the beginning of the action with the first person that
was involved.
(b) Ask about facts and details to get a clear picture.
(c) Bring in others as they joined the action.
(d) Provide the opportunity for everyone to retell what he saw and did so
that the big picture can be seen and agreed upon by everyone.
(e) Make a special effort to involve those who are silent and seem not to
want to talk, but do not require anyone to speak.
(4) Share thoughts and reactions to the action.
(a) Do not ask specifically about emotions and feelings or force anyone to
talk about them if he does not want to.
(b) Wait until the facts are clear, then ask about the thoughts that came to
their minds during the action.
(c) Ask what were their reactions to those thoughts.
(d) Allow feelings to come out naturally, either in words or in the tone of
voice, facial expression, body posture, or even tears. The feelings should
then be acknowledged and validated by the leader and the rest of the team.
This will encourage others to be more open about their feelings.
(e) Keep this a positive learning experience in which natural human
emotions and mistakes, however painful or "bad," are accepted as natural
but controllable.
(f) Prevent scapegoating or isolation of individual soldiers.
(5) Encourage talk about any physical or mental signs of battle fatigue anyone
may be having if the action was a high stress event.
(a) Remind personnel that battle fatigue signs are a normal reaction.
(b) Ensure personnel that the battle fatigue signs normally improve with
time and talk.
(6) Bring the focus back to the mission after the feelings have been recognized
and ventilated.
(a) Expand on the mission.
(b) Encourage talk on what was learned and how to do it better the next
time.
(c) Review what went well and the positive things that were accomplished.
(7) Use after-action debriefings to orient new unit members. These debriefings
familiarize them with the unit's most recent history, introduce them to the
veterans' roles and personalities, and acquaint them with the unit's TSOP. It also
helps when merging survivors of two units into one, with or without other new
replacements.
A-3. First Exposure
a. Risk Factor: First exposure to a major stressor.
(1) The first exposure to a significant stressor is usually a time of high stress and
risk of battle fatigue. Likewise, it is inevitable when a unit or individual first
encounters true combat with its extreme noise, confusion, wounding of soldiers,
and violent death. Tough, realistic training helps, but no training can fully equal
the real consequences of kill-or-be-killed. The shock will also be intense for
medical personnel, even in rear area hospitals, unless they have had extensive
emergency room experience.
(2) Even experienced troops may suffer increased battle fatigue when confronted
with a surprise enemy weapon, tactic, or attack. Examples include the following:




The first exposure to tanks and gas in WWI.
German blitzkrieg tactics with Stuka aircraft, the "88" antitank gun, and
later the "Screaming Meemie" mortar.
Improved conventional munitions and napalm bombs (Israel against
Egypt, US against North Vietnam) and wire-guided antitank missiles
(Egypt and Syria against Israel).
Strange, hostile terrain and climate. This type stressor can demoralize even
experienced units. (At first, a crack Australian division suffered severe
stress casualties when suddenly transferred from the desert of North Africa
to the jungle of New Guinea.)
b. Leader Actions: Conduct rugged, realistic training.
(1) Build soldiers' confidence in their own ability, their leadership, and their
equipment, initially through rugged, realistic training, and later through success
on the battlefield.


Tough means hard work and continuous operations even during inclement
weather conditions.
Realistic means as similar to the combat mission and combat environment
as possible, including the noise, smoke, dust, confusion, delays, setbacks,
casualties, and simulated danger and sights.
(2) Seek out challenging and difficult environments for training to increase the
unit's skills and confidence. The purpose is not learning to suffer. The objectives
of this training are twofold:


First, learn to accomplish the mission in spite of suffering.
 Build toughness, tolerance to discomfort, and the confidence that
we can take it and do the job.
 Perform essential tasks for mission accomplishment while adapting
to combat and defending against enemy attack.
Second, learn how to suffer as little as possible.
 Know how to take care of yourself and each other so that everyone
comes through "OK," even though the conditions are stressful.
 Educate the soldiers to maintain themselves, each other, and the
equipment as a matter of professional pride and personal caring,
rather than just as discipline. Explain why it is important, not just
picky details.
(3) Emphasize that the ultimate result should be success.
(4) Use tough training to achieve specific objectives:





A-4. Unit Casualties
Learn each soldier's strengths and weaknesses.
Maximize soldier's strengths while learning how to minimize his
weaknesses.
Identify which are the truly key combat mission tasks. These are given
training emphasis. However, remember that some unglamorous things like
preventive maintenance and resupply can be truly critical.
Identify the best qualified soldiers to perform those key tasks. Individuals
do differ in training, adaptability, and ability to learn under stress.
Cross-train! There must be several people capable of doing every key task,
including leader tasks and yours.
a. Risk Factor: Casualties in the unit.
o
o
o
Soldiers in the unit being killed and wounded is the strongest indicator of "combat
intensity" and usually is accompanied by increased battle fatigue casualties. This
is especially true if many casualties occur in a short time.
Heavy casualties naturally shake soldiers' confidence in their own chance of
survival. The impact is strongest if losses are in the soldiers' own small unit. Loss
of a trusted leader or close buddy is both an emotional shock and a threat to unit
integrity and survival. New replacements are an unknown quantity who may not
know the TSOP and cannot yet be fully relied upon. Losses naturally arouse the
battle fatigue symptoms of reduced confidence, feeling exposed and abandoned,
and perhaps guilt, anger, and mistrust.
These feelings will be magnified if the soldier does not feel that everything
feasible was done to care for and evacuate the wounded and that respect for the
dead was not shown. Confidence in the health service support system can help
compensate for the fear of being wounded.
b. Leader Actions: Prepare the unit to endure battle losses.
(1) Talk frankly and prepare for the possibility of casualties in the unit and of
team members being killed.




Talk in the unit about possible loss of leaders and unit members. It will
happen in war (even in CSS units) and must not come as a surprise.
Train junior leaders to take over when senior leaders need sleep or if they
become casualties.
Keep the junior leaders as continuously informed as possible so that they
can assume command on short notice without missing stride.
Cross-train soldiers so that every key task can be performed proficiently
by several soldiers.
(2) Routinely practice casualty care and evacuation.



Train everyone on basic lifesaving self-aid/buddy aid. Select the best
soldiers for additional combat lifesaver training, one for every team or
crew. Practice this routinely.
Practice realistic use of any assigned medical personnel and evacuation of
casualties as part of any combat exercise. If you can occasionally get
moulage kits to make soldiers appear to have serious battle wounds, this
will help to harden your soldiers to better face some of the sights of battle.
Practice self-aid/buddy aid techniques for battle fatigue.
(3) Conduct the small team after-action debriefings after any losses (in training
and in combat).
(4) Conduct memorial services for the unit's dead. This will help the soldiers in
grieving, provided the service is done with sensitivity.


While a unit chaplain may play an important role in this service, the
commander and junior leaders should be the main participants.
The dead soldier's friends and others who knew the soldier personally
should have an active part in the planning the services, as well as special
roles in the ceremony. All ideas should receive equal consideration.
(5) Plan ahead for a rapid, positive integration of new personnel.
A-5. Passive Posture, Defenseless to Attack, or Hit by Friendly Fire
a. Risk Factor: Under attack and unable to strike back.
o
o
o
o
Indirect (artillery) fire usually causes more battle fatigue casualties in relation to
killed and wounded than does direct fire. This is partly because of the massed,
impersonal destruction that a barrage can cause.
Even more, it is because the troops feel themselves helpless victims of pure
chance. Armor and air attacks also tend to produce disproportionate battle fatigue
casualties in troops who are not trained to shoot back, such as rear area support
units.
In WWII, many battle fatigue casualties were attributed to the troops' perception
that German tanks, "88" artillery, and other weapons were far better than our own,
so that we did not have a fair chance to strike back.
In operations other than war (conflicts), similar frustration is produced by hidden
snipers who fire from areas where return fire is limited by the rules of
engagement. It may be caused by mines and booby traps and by combatants who
cannot be distinguished from the civilians one is supposed to protect. However,
this is more likely to trigger misconduct stress behaviors than battle fatigue.
b. Leader Actions: Train troops in active defense against these threats.
(1) Prepare units for the experience of being bombarded.



Expose all troops in training to the sights and sounds of heavy artillery or
air attack impacting at close range. This can be done in suitably safe
bunkers, ideally with live artillery fire, but if that is unfeasible, with
pyrotechnics and sound effects.
Explain to the troops that dug-in but inexperienced troops usually believe
that everyone else has been killed in a barrage and are surprised when
everyone (or almost everyone) climbs up out of his holes when it is over.
Train how to dig in to protect against bombardment. Dig in at every
location (balancing the amount of digging against other missions, enemy,
terrain, troops, and time available factors). Take pride in camouflage,
dispersion, and light discipline.
(2) Train soldiers in active defensive tactics.


Drill troops in how to defeat infantry and armor forces.
Drill troops in air defense tactics. Train all who are not in the direct path
of an attacking aircraft to engage it with their rifles. This is as much a
protective measure against battle fatigue as it is an air defense technique
since it changes them from being helpless victims to being hunters who
are helping their buddies.
NOTE
Being hit by friendly fire (whether direct or indirect) or losing troops in a
senseless accident produces more battle fatigue because one cannot strike
back and it seems so needless.
(3) Drill to prevent friendly fire casualties.



Drill relentlessly in identification of combat vehicles, equipment, and
aircraft to minimize mistakes in identification.
Remind everyone that our weapons and those of our allies and potential
adversaries have been sold around the world and could end up on either or
both sides in any conflict. Know the weapons the enemy is using. Drill to
identify enemy weapons and weapons systems by name.
Practice rigorous coordination and communication within and between
units.
 Ensure all personnel are proficient in and knowledgeable of the
procedures for challenging, identifying, and communicating with
US and allied ground and air forces. Practice these procedures
frequently during all operational and environmental conditions to
identify and correct any deficiencies.
 Inform everyone, down to the lowest level, of the friendly forces
likely to be encountered in the scheme of maneuver, but be alert
and ready for the possibility of change without notice, including
the enemy appearing where friends are expected and vice versa.
 Continually conduct risk assessment and control procedures.
(4) Frequently review the TSOP for rules of engagement, danger, and close fire
support, and modify or change as required. Maintain the best balance between
suppressing or destroying the enemy's capability to inflict damage on us while
preventing mistaken fire on friendly forces.
A-6. Immobility
a. Risk Factor: Immobility during static, heavy fighting.
o
The highest rates of battle fatigue have usually been in static situations where the
fighting is heavy, resulting in little opportunity to move around. This occurs when
o
troops are pinned down in bunkers, trenches, or ruins (WWI and Korean War
trench lines, Anzio in WWII). It occurs for the attacker and the defender who
must fight at close quarters, day after day, and for armored troops when they are
deployed on restrictive terrain.
Conversely, during highly mobile warfare, whether maneuvering in battle,
pursuing, or even in hasty retreat, obvious battle fatigue symptoms and casualties
often are not recognized until a safe place or stable lull is reached. (However,
many soldiers may have been killed, wounded, or missing as a direct consequence
of battle fatigue symptoms but were not classified as battle fatigue casualties.)
b. Leader Actions: Recognize the static, heavy fighting and institute protective measures
for trench, bunker, or urban warfare.
o
o
Rotate units frequently back to reserve positions where they can move around
freely whenever the tactical situation permits.
Keep the troops informed and try to give them the best possible support for food,
water, clothing, supplies, and mail up to the farthest forward positions.
A-7. Lack of Information/Support
a. Risk Factor: Lack of information and failure of expected support. When troops do not
know what is planned, they feel isolated, unappreciated, and forgotten. Whenever support
or relief does not show up, they may feel deserted. This is especially true if the failure is
unexplained. They lose the perspective of the greater mission and are less able to
maintain a positive perspective on the combat stressors. They tend to fear the worst, and
rumors take hold and lead to battle fatigue and even panic.
b. Leader Actions: Keep information flowing.
(1) Keep yourself informed.


Actively seek out information from the chain of command, the chain of
support, and other reliable sources.
Do not ignore less reliable sources of information, but try to get
confirmation before committing totally to act on it.
(2) Keep all the troops informed with the best, honest information.


Keep the troops well informed of their goals, the situation, and how they
are doing. Information flow must be a routine, ongoing process which is
transmitted down to the lowest level. Explain to troops that information
will be disseminated through the chain of command.
Use in-country public affairs assets. Public affairs can play a key role in
helping commanders meet the communications needs of their soldiers.
Public affairs officers advise commanders and their leaders on the
information needs of units, assisting in the development of messages,

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
facilitating the flow of information, and providing communications
channels.
Stop rumors and counsel rumor-mongers while giving out the best, most
reliable information you have, with appropriate caveats about its
limitations. Remember, even telling the troops that you do not have any
new information is meaningful information to them. It lets them know that
you are keeping them informed.
Tell the troops what kind of supporting arms are expected, but explain that
other units and missions also have a claim to them -- and support may not
be immediate.
Do not conceal unpleasant possibilities, but put dangers in the perspective
of how the unit will prepare to overcome them. Always give them some
guidance they can begin to act on and not just sit and worry.
When operational security does not permit informing the troops on
upcoming operations, keep them informed in other areas. Once the
security requirements are lifted, brief the troops and provide as much
information as possible.
A-8. Nuclear, Biological, and Chemical Weapons
a. Risk Factor: High threat of NBC weapons use and actual use. The invisible, pervasive
nature of many of these weapons creates a high degree of uncertainty and ambiguity with
fertile opportunity for false alarms, rumors, and maladaptive stress reactions. The terrible
nature of some of these weapons will create fear for the future, the homeland, and
perhaps even for the survival of civilization.
b. Leader Actions: Prepare troops for NBC threat contingencies.
(1) Keep information flowing, dispel myths, and control rumors.


Discuss the situation and its possible long-term implications honestly.
Maintain the view that the best chance for the future will be maintained if
the unit stays effective.
(2) In training, emphasize that our intention is deterrence.

Tell the lesson of history that NBC weapons are much less likely to be
used against us if we show by our defensive training that they will not give
an enemy enough advantage to justify the risk of his using them against
us. If we train and the enemy does use them, we also have our best chance
of surviving and winning.
(3) Put NBC (and especially chemical) defense in realistic perspective.

Point out that low-dose exposure will be much more common than highdose (potentially lethal) exposure.


Compare the risks of the most likely threat with the increased risk of
facing the conventional threat in varying levels of MOPP. Think of the
decision to put yourself or your unit into MOPP as being like the decision
of how much cover to take when under the threat of conventional weapons
when you have a mission to accomplish.
Change to MOPP levels that permit accomplishment of the mission and
survival of the soldier.
(4) Practice flexible MOPP procedures when there is only a threat of chemical
agent use, or low doses in the surrounding areas, and there is a critical mission to
be done that is impaired or endangered by MOPP.



Mission-oriented protective posture flexibility means that some team
members perform the mission-essential heavy work, fine finger
movements, and visual and auditory tasks at a lower level of MOPP (or
mask only) while others stay at a higher MOPP level.
Those in high MOPP stay ready to take over the task and provide
assistance to the members of the first group as they go to MQPP Level 4 if
the unit is hit with chemicals.
In any potential biological or chemical risk situation, some members of the
unit are at some protective level at all times, with MOPP rotation set by
the TSOP.
(5) Emphasize buddy aid by those in MOPP rather than self-administration of
antidotes such as atropine, which may have harmful effects if taken in the absence
of nerve agent.


Soldiers may take the first autoinjection of atropine (Mark I Kit) if they
believe they have been exposed.
Get to a buddy to confirm the symptoms within 10-15 minutes and
administer a second Mark I only if it is truly needed.
(6) Reduce ambiguity by having a unit TSOP with clear, objective criteria for all
levels of MOPP.



Some members of the team automatically mask or go to MOPP Level 1 or
2 whenever any unidentified aircraft are seen, or potentially contaminated
patients arrive, or there is incoming artillery or smoke. They monitor the
detection equipment and prepare to give aid if agents are present.
Those who are performing critical jobs which cannot be performed well in
mask or overgarment continue to perform those tasks. They stay ready to
go to a protective posture immediately if a NBC threat is confirmed.
Specify in the TSOP how to decrease MOPP levels and unmask
sequentially as a team, not all at once. The unmasking drill needs to be
practiced. Give active reassurance to the first group to unmask, assuring
them that their buddies are observing and can help them if any harmful
agent is present.
(7) Train in the protective mask often and require prolonged wear. It takes
repeated familiarization and time to acclimate and get over the common
claustrophobic feeling. The respiratory threat from almost all NBC agents is much
greater than the skin contact threat. Inhaled nerve or cyanide kills in minutes.
Inhaled blister and choking agents act slowly, but once they are in the lungs, one
cannot get them out. Absorption of most agents through the skin is slower. This
allows time to wash them off and use antidotes if available.





Start with enjoyable activities to overcome initial anxiety.
Wear the mask often in garrison, even at desk jobs. The more often
soldiers wear their mask the quicker they become familiar with it.
Have periodic prolonged wear (8+ hours) to help soldiers realize they can
tolerate the discomfort of the mask.
Wear the mask while performing tasks which relate to combat duties.
Wear the gloves often (with and without mask) until most of the essential
jobs can be done in them.
(8) Train sometimes in MOPP Level 4 (or simulated MOPP Level 4, which is to
overdress while wearing the protective mask, overboots, and gloves). However,
this training is less important than mastering the mask alone.
(9) Issue each soldier his own personal mask whenever feasible. This ensures that
each soldier's mask is the correct size and places responsibility for care of the
mask on each soldier. A soldier will feel more trust, confidence, and even
grudging "cohesion" for his mask if it is his and he is issued the same mask every
time.
(10) Use any mask confidence exercise only as a culmination of training and
proof of success. This requires teams to enter an area where a riot control agent
has been released and -



Perform their team jobs together.
Drink water through the drinking tube.
Unmask briefly while holding their breath and keeping their eyes closed.
Remask, reseal, and clear the mask before breathing. The soldier can then
leave without feeling unpleasant symptoms from the tear gas if everything
works well. The purpose of the exercise is to build confidence in the mask,
not to destroy it.
(11) Emphasize professionalism in training.

Conduct cross-training to allow effective crew rotation and physical
conditioning which extends the limits of the soldier.



Emphasize the common soldiering skills.
Emphasize that we train to do our missions this way because it is the
TSOP. We do it because we are smart, survival-skilled soldiers.
Practice all critical tasks with at least the mask on until they can be done
automatically. This is essential.
Simple routine or overlearned tasks are the least susceptible to degradation.
(12) Leaders must be positive role models. They must be highly visible and
positive in doing the MOPP training themselves.
(13) Make NBC field training exercises realistic.


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

Integrate NBC conditions into realistic training exercises. Cohesion and
esprit de corps are achieved by working together to overcome (or prevail
in spite of) hardship and discomfort which NBC training provides.
Work together as a team to develop coping techniques which deal with
individual limitations encountered while performing routine tasks during
realistic training.
Develop and practice ways to identify individuals in MOPP, to assess their
alertness, comprehension, and well-being, and to give and receive
emotional support.
Make frequent use of simulated agents such as methyl salicylate (oil of
wintergreen). These provide realistic practice with detection equipment
and protective gear.
Teach threat limitations as well as strengths. For example, teach that the
threat is not everywhere but decreases with distance from point of
dispersal and time and can be reduced by skilled use of terrain, cover, and
wind direction.
Stress the need for contamination avoidance and use of collective
protection and decontamination means. Also stress individual, crew, and
unit proficiency in the tactics, techniques, and procedures of NBC defense.
Make exercise scenarios plausible. Exercise detection, monitoring,
reporting, and risk estimation.
Use reports of nuclear weapons explosions only if they fit well in the
exercise scenario. Since we cannot adequately simulate a real nuclear
burst, use "precautionary alerts" to exercise TSOP.
Make the dispersal and "hardening" of a unit's position the unit's standard
way of setting up (so that it is less vulnerable to nuclear flash and blast).
Reinforce this by frequent practice of nuclear blast and radiation
protective drills, both for what to do with a few minutes advance warning
and for when the first warning is just the flash.
(14) Train hard and be prepared to manage heat stress in well-acclimatized, fit
soldiers. We must push our well-prepared troops to a level of acceptable risk.


Be alert and fully prepared to manage heat stress (heat cramps, heat
exhaustion, and even the exceedingly early signs of heat stroke [which are
revealed by mental symptoms of elation, confusion, disorientation, and
perhaps hallucinations and belligerence before they progress to coma,
seizures, and danger of permanent brain damage or death]).
Take this risk only after specific preparation of every soldier involved and
of the unit. Adequate preparation includes - Physical (aerobic and muscle) fitness.
 Acclimatization to the area of operations and conditioning to
various MOPP levels, especially MOPP Levels 3 and 4.
 Acclimatization by doing more work in hot conditions.
 Water availability and command emphasis on drinking "by the
numbers" (so much per hour).
NOTE
Leaders must be concerned about soldiers' health, but they should
be careful not to lose credibility through overreaction to perceived
hazards.


 Skin and foot care.
Medical awareness with backup personnel and preparation of evacuation
means.
Management of psychological stress symptoms, such as hyperventilation,
by using self-calming relaxation and buddy aid techniques.
WARNING
Unfit, unacclimatized troops should not be overexerted in training as
this could cause severe injury or even death. A special physical
training program will be required to integrate such soldiers into a
regular Army physical training program.
(15) Emphasize the importance of timely prophylactic/treatment materials once
the causative chemical or biological agent is known.
A-9. Deprived of Sleep
a. Risk Factor: Sleep loss. Battle fatigue can occur without sleep loss, but insufficient
sleep can be a major contributing factor. The sleep-deprived soldier or leader has
difficulty thinking and reasoning and becomes easily confused and overly suggestible
with poor judgment. Pessimistic thinking takes hold and everything seems too difficult.
Sleep loss alone can cause the tired brain to see things which are not there (visual
hallucinations) or to perceive things which are there as something totally different. When
anxiety and vigilance (staying awake on watch) are added, the soldier may be temporarily
unable to distinguish between reality and what he fears. Normal physical symptoms of
stress can become magnified into disabling illnesses.
b. Leader Actions: Practice sleep discipline and sleep planning. Sleep discipline means
sleeping when and where you are directed. Sleep discipline is intended to provide the best
sleep possible in the time and place available. Because battle is both stressful and
unpredictable, a flexible plan is needed to supply everyone with sufficient sleep.
(1) Set shifts whenever possible.


Shifts which allow each individual 6 to 8 hours of continuous sleep when
feasible are preferred. Provide soldiers with a minimum of 4 hours of
uninterrupted sleep in a 24 hour period (6-8 hours optimum). This greatly
extends soldiers and crew endurance limits.
The standard wartime shift is 12 hours on and 12 hours off (two shifts per
day). This has the advantage of simplicity, requires fewer skilled
personnel, and has only two shift changes when information must be
exchanged.
(2) Supervisors should consider alternative shift plans, if flexibility of sleep hours
is required in a combat mission situation. For many jobs, 12 hours on duty may be
too mentally or physically exhausting, leading to poor performance in the last
several hours. Or the work load may be so variable that it is sometimes necessary
to keep both shifts on duty, in which case one shift may have to go 36 hours
without sleep.



The sleep does not have to be continuous. While 6 to 8 hours of
continuous sleep is preferred, studies show that several blocks of sleep
which add up to 6 hours in 24 are adequate for most people. The fewer the
blocks, the better.
Consider two shifts per day, each working 6 hours on, 6 hours off, (or 6
1/2 on, 51/2 off, with overlap for shift changes). This works everyone half
the time, but gives everyone two chances each day to get 3 to 5 hours of
sleep. The world's sailing navies used 4 hours on, 4 hours off for centuries
because of the heavy work and frequent need to call all hands on deck.
Use the 6 hours on, 6 hours off alternative only in work situations where
the duty station, dining facility, sleeping quarters, and other essentials are


close together, such as in small base areas. Otherwise, too much time is
wasted going back and forth to quarters and the dining facility.
Ensure all essential information is transmitted and understood when the
shifts change.
Avoid shifts which set the period of sleep at different times each day -such as 8 hours on, 8 hours off. This tends to disrupt the body's 24
hour/day biological rhythm and leads to poor performance as well as
personal discomfort. Whenever possible, people should get at least some
sleep at the same time each day.
NOTE
In CONOPS, if shifts are impractical, try to give all individuals at least 4
hours of uninterrupted sleep each 24 hours (5 hours if sleep is interrupted).
(3) Identify and take special precautions to protect the performance of those
critical tasks which are vulnerable (sensitive and likely to break down) due to
sleep loss, especially planning, initiating, reasoning, cognition, and vigilance.
Remember, 4 hours each 24 hours is far from ideal.


Do not go with only 4 hours sleep each 24 hours for more than 1 or 2
weeks before paying back sleep debt.
If at all possible, give the individuals whose key tasks are vulnerable to
sleep loss 6 hours sleep a day.
(4) Assign naps.



It is helpful to get 1 hour sleep here, 2 hours there. Even a little sleep is
better than none. It is not necessary that it all be in one block.
Even brief ( 15 to 30 minute) naps help against sleep debt. However, 5minute naps do not help.
Plan time to wake up from naps. After a nap, mental task performance is
often much worse for several minutes after waking up than it was just
before the person went to sleep. The brain needs time to "warm up."
(5) Practice counterfatigue measures to use when soldiers must continue to work
or fight without enough sleep.

Use ways to increase alertness.
 Add changing sensations. Of course, this must not interfere with
the task. For example, one can listen to the radio while driving on
the highway at night but not on guard duty. It is best for the soldier
not to be too comfortable. He can snack on something with a
strong taste. Protein is better than carbohydrates for staying alert.
Caution is needed in using stimulant drugs. Caffeine (coffee, tea,
and cola) is relatively safe for most people for short-term use, but
may make it difficult to sleep when opportunities arise.

Amphetamines and other strong stimulant drugs are more
dangerous; they can cause panic attacks, hyperactivity, and
temporary paranoid psychotic reactions which last several days.
Also, people "crash" when they stop using such strong stimulants
and many even get seriously depressed.
 Add physical movement if the task lacks it. The soldier should take
stretch breaks and jog to increase circulation. He should fidget in
place if he cannot leave the duty station.
 Add social stimulation. Use the buddy system, assigning two
people to work together. Of course, this means one fewer person is
getting time to sleep. With workers who must be at different
isolated locations, alternate having them call each other by radio or
telephone to ensure that they remain alert.
 Add sense of urgency. Brief troops about the urgency of the task.
Be sure to explain why it is important to stay awake. If it is hard to
keep urgency in mind, use "game playing" to maintain interest by
adding competition or suspense.
 Add feedback of performance. If the task does not automatically
provide feedback, actively try to create it. The leader can provide
feedback by spot-checking for compliance, building feedback into
the task, and contacting the users of the service to make sure they
are satisfied.
 Rotate jobs. If the job requires continual attention or is physically
demanding, it will be vulnerable to sleep loss. If you cannot
provide breaks, try having people switch jobs, preferably to
something quite different. This can give surprising improvement in
performance, provided the soldier knows how to do the new job
well. In order to rotate jobs, you must have cross-trained personnel
in advance. Make sure all essential information is exchanged,
understood, and recorded when the switch is being made.
Otherwise, worse difficulties may result.
Use ways to support memory.
 Clarify and modify the task. Try to simplify orders and complex
sequences. This has to be done before people get too tired to use
good judgment. Double-check such sequences (get independent
verification). Document in writing what was done.
 Use performance aids, if new learning is needed. Take notes. Draw
simple diagrams or maps to involve visual-spatial memory as well
as verbal memory. Write down all orders and read back input to
ensure that it has been understood and copied correctly. Refer to
these aids later when short-term memory has forgotten exactly
what was said.
 Drill the task to "overlearn it" until it is automatic. The common
saying is "He knows it so well he can do it in his sleep." Even
complex tasks will be resistant to sleep loss if they have been




practiced until they need only be started to run themselves through
to completion without having to think about them.
 Build in cues and reminders of the self-initiated parts within the
task itself or the situation. Have checklists and TSOP, put up signs,
write notes -- then practice! This is especially relevant for tasks,
such as preventive maintenance and ordering more supplies. These
are easily omitted by tired workers, but the whole mission may
collapse suddenly if they are not done.
Determine performance decrement factors through realistic mission
training in MOPP Levels 3 and 4. These factors can then be used to state
realistic mission requirements for units and crews.
Divide the labor (task paralleling). Put more people to doing the entire job.
This works if having more people doing the same overall task means less
work for each person and especially if it gives more time for each element
of the task. Of course, it also means that fewer people are getting to sleep,
and it is harder to coordinate the information, so do this only for essential,
critical tasks. Let the other tasks wait (see priorities, below).
Divide the responsibilities of the time-shared task where one person
normally has to do two or three things all mixed together. Assign several
people, but modify the task so that each person has responsibility for only
one task element and can concentrate fully on it. The hidden danger of this
remedy shows up if several people must transmit information among
themselves, since communication and memory are impaired by sleep loss.
Simplify priorities. Sleep-deprived people have trouble deciding what is
most important. They tend to hang up on choices (taking longer and
longer, or not choosing at all), or they unthinkingly do what is easiest, or
most learned, or most obvious. Specify what is most important versus
what should be dropped out. You should decide this while fresh, build it
into your TSOP, and practice it.
(6) Get good sleep before CONOPS or an afternoon nap before night operations.
You cannot "stockpile" sleep, but starting out without any sleep debt delays the
onset of degraded performance.

In CONOPS or SUSOPS, never waste a chance to let someone in the unit
sleep. Spread such opportunities around to give everyone enough.
NOTE
Be careful. Do not allow sleep in unsafe conditions, such as under vehicles
or in vehicles with the motors running. Beware of the tendency for tired
people to slack off and use poor judgment.
A-10. Physically Run-Down
a. Risk Factor: Run-down physical condition. This contributes to battle fatigue by
sapping soldiers' ability to function and, therefore, their confidence to accomplish the
mission and survive. Neither physical fatigue nor sleep loss necessarily cause battle
fatigue, but they can be strong contributing factors. To the extent that these factors are
involved, they are easier to prevent or correct than are most of the factors listed earlier.
The more physical exhaustion is present in battle fatigue casualties, the more confident
we can be that soldiers will recover completely. These soldiers return to duty once we
have replenished the physical resources. However, our treatment must also restore their
confidence.
(1) Dehydration deserves special mention because it can be extremely subtle.


A stressed soldier under battlefield, MOPP, or heavy work conditions can
become exceedingly dehydrated without feeling thirsty. This is especially
true in hot climates, in MOPP, or the arctic. Dehydration renders the blood
less able to carry oxygen to the brain and muscles. This results in instant
battle fatigue.
Colonel (later Brigadier General) S.L.A. Marshall, the US Army historian
who pioneered the technique of interviewing combat teams while the
battle was still going on, discovered this in himself during his first
exploratory mission on Kwajalein in WWII. Colonel Marshall was a man
who was literally fearless, so this came as a surprise to him. He
summarized the lesson by writing, "No one ever told me that dehydration
causes cowardice in its most abject form."
(2) Poor diet is common, if not inevitable, in combat and tends to lower one's
energy level and sense of being strong and alert. While some people eat more
when anxious or depressed, most eat less. Stomach pain and nausea are common
signs of battle fatigue which further inhibit eating. The monotony and
unpalatability of some meal(s), ready to eat (MRE) or tray-packs (T Rations), will
not help. Such rations are even less likely to be eaten if they must be eaten cold.
Many soldiers may start eating only a few, select items which do not provide allaround nutrition.
(3) Poor hygiene is common, if not inevitable, in combat and tends to lower one's
energy level and sense of being alert and "human." We have all had the
experience of coming in from days out in the field, dragging, and how much
better we felt after that first hot shower. Imagine how much worse the "dragging"
is if that poor hygiene goes on for weeks. Poor hygiene can also lead to disease.
(4) Low-grade environmental or stress-related illnesses further sap the soldiers'
strength and confidence. Chronic diarrhea, persistent cramps in the stomach, fever
from malaria or virus, or skin infections or blisters that do not heal can make
soldiers feel exhausted and demoralized, setting them up for battle fatigue. Units
whose leaders do not monitor and enforce basic preventive medicine and hygiene
measures are likely to suffer low morale and high battle fatigue rates. Conversely,
being in a unit where a sense of caring, order, and TSOP is maintained is a strong
stress reducer. It not only maintains health but also promotes unit pride, cohesion,
and confidence.
b. Leader Actions: Protect the physical well-being of the troops. In combat, never waste
the strength of the soldiers for trivial matters because there will be many occasions when
it will be necessary for soldiers to accept hardship to gain the advantage.
(1) Ensure the best water, food, equipment, shelter, and sanitation (and sleep)
possible under the circumstances of the mission.





Enforce water discipline.
Enforce food discipline; ensure soldiers eat an adequate balanced diet
from their MRE, T Rations, or A Rations.
Enforce basic personal hygiene and preventive medicine practices.
Assure latrines are kept clean.
Provide time for troops to bath or shower at least once weekly and more
often when feasible.
(2) Explain why the hardship is necessary when unable to provide well for the
soldiers' physical needs.


Put it back in the perspective of how "we will cope."
Remind them of those times in earlier training when they overcame the
hardship to accomplish the mission.
A-11. Inadequate Fitness
a. Risk Factor: Lack of physical fitness. Being physically fit is not a guarantee against
becoming a battle fatigue casualty, but not being physically fit is an invitation for it.
Sudden overuse of the cardiovascular system, muscles, joints, and bones that have not
been prepared for the strain can lead to immediate failure and serious injury. Even if
these are avoided, the unfit soldiers will be subject to days of stiffness, aching, and
weakness. During this time, they are at extremely high risk for battle fatigue, especially if
further demands are made on them.
b. Leader Actions: Assure physical fitness.
o
o
Physical fitness programs are useful in promoting unit cohesion, but they are also
important in themselves as protection against battle fatigue. Being super-fit is not
a guarantee against disabling battle fatigue, but it does increase self-confidence
(and the confidence of buddies) and delays the onset of muscular fatigue.
Assure that everyone in the unit has - Aerobic fitness (endurance).
 The necessary muscle strength in the parts of the body which they will use
in their combat role.
 Calluses in the right places (to avoid developing blisters).

The necessary flexibility and agility for the tasks to be done, including the
combat self-defense tasks like digging. This is especially necessary for
some combat support/CSS personnel whose garrison or field jobs tend to
be sedentary.
A-12. Older Veteran or Short-Timer
a. Risk Factor: Cumulative combat exposure or "being short."
o
o
o
o
These are special situations where the individual is at high risk for battle fatigue.
The "old sergeant syndrome" of WWII occurred in the veteran soldier who had
been in combat for a long time. He had risen to a responsible position but had
seen all his old buddies killed or wounded and replaced by new, inexperienced
soldiers. The only way home was death, mutilation, or, if exceedingly lucky, the
"million dollar wound." Although he often insisted that he wanted to stay in
combat, he felt guilt at his weakness. He had become overly cautious, indecisive,
anxious, and depressed.
An "old sergeant" variation, seen also in Vietnam, was the NCO or officer who
extended for a second or third tour but who was so embittered and hardened to
combat that he was in danger of committing some of the misconduct stress
behaviors.
"Short" soldiers are those who are coming close to the date when they will rotate
home from the combat tour. Neither they nor their buddies want them to get hit on
their last day (or week, or month, or mission) in combat. This was a common
experience in Vietnam (with the 365-day tour) and in Korea (with the "point
system" used late in the war). In WWII, it was seen in aircrews who rotated home
after some number of missions, and in the Marines when it was established that
they would be rotated home after three amphibious operations. A similar reaction
may occur in the last days before an expected cease-fire or armistice.
b. Leader Actions: Recognize and manage the "old veteran" or "short-timer" syndrome.
o
Maintain a rotation schedule which avoids relieving soldiers from dangerous duty
prematurely at the expense of others, without keeping them in so long that they
become ineffective and dangerous.
 Develop rotation standards based on the overall situation.
 Reassign the "old veteran" to a responsible rear echelon job rather than
risk a serious failure in combat or a case of battle fatigue that does not
respond to treatment and leaves the soldier permanently scarred.
 Support and protect those individuals who are showing more signs of
battle fatigue than the average. This is done without creating a social
expectation of relief from dangerous duty that saps the fighting strength.
 Use judgment when discussing this topic so that it does not become a
"self-fulfilling prophecy."
o
o
o
o
o
Do not set an automatic policy of relieving "short" soldiers from dangerous
missions during their final weeks. This will move the "short-timer" syndrome
even earlier in the last months.
Give the individual soldiers (or units) who are preparing to rotate home a period
of several days of minimal danger just before departure.
 Schedule this time for postdeployment debriefings. These sessions are
similar to the routine after-action debriefings but on a larger scale.
 Concentrate on remembering and reviewing in detail the major events
(good and bad) of the tour, sharing the common experiences and feelings.
 Actively work through unresolved, painful, or controversial issues.
 Discuss (receive briefings on) how the home front (family, Army, nation)
may have changed or may react to returning veterans and their needs.
 Normalize the common postcombat (traumatic) stress signs/symptoms
most will have.
 Review coping techniques.
Conduct a suitable memorial ceremony prior to departure from the combat zone to
provide a sense of completion and closure for those soldiers returning home.
Coordinate with the rear detachment and family support group to schedule
information briefings pertaining to redeployment of the unit to its home station.
Plan a welcome home/memorial ceremony which includes the family and garrison
community.
APPENDIX B
ORGANIZATION AND FUNCTIONS OF
ARMY MEDICAL DEPARTMENT
COMBAT STRESS CONTROL UNITS
B-1. Introduction
Combat stress control is now recognized as an Army Medical Department functional area for
doctrinal and planning purposes. As such, it is distinguished from the other nine Army Medical
Department functional areas of health service support which are -a. Patient evacuation and medical regulating.
b. Hospitalization.
c. Health service logistics/blood management.
d. Dental services.
e. Veterinary services.
f. Preventive medicine services
g. Area medical support.
h. Command, control, communications, computers, and intelligence (C4I).
i. Medical laboratory services.
B-2. Army Medical Department Combat Stress Control Program
a. Combat stress control refers to a coordinated program for the prevention and treatment
of battle fatigue and other harmful stress related behaviors. Combat stress control is
implemented by mental health personnel organic to units and by specialized medical
combat stress control units which are a corps-level (or echelon above corps) asset. The
combat stress control organization must function flexibly across the full range of combat
intensities and operational scenarios including war and operations other than war.
b. There are six major combat stress control programs or functions which have different
relative importance in different scenarios. The usual order of priority is as follows:
(1) Consultation. Liaison, preventive advice, education programs, planning, and
stress control interventions to supported unit commanders and staff.
(2) Reorganization (reconstitution) support. Assistance at field locations to battle
fatigue units which are withdrawn for rest, reorganization, and integration of new
replacements.
(3) Proximate neuropsychiatric triage. Sorting battle fatigue cases based on
where they can be treated to maximize return to duty, separating out true
neuropsychiatric or medical/ surgical patients.
(4) Stabilization. Immediate, short-term management and evaluation of severely
disturbed battle fatigue casualties, neuropsychiatric, and alcohol and drug misuse
cases to determine return to duty potential or to permit safe evacuation.
(5) Restoration. One to three days of rest, replenishment, and activities to restore
confidence of battle fatigue casualties at "forward" medical units.
(6) Reconditioning. An intensive 4- to 21-day program of replenishment, physical
activity, therapy, and military retraining for battle fatigue casualties and
neuropsychiatric cases (including alcohol and drug misuse) who require this to
return to duty.
B-3. Basic Tenets of Army Medical Department Combat Stress Control
a. Army Medical Department combat stress control is unit-identified and missionoriented.
(1) The combat stress control concept differs from conventional clinic or
community mental health in its explicit identification with and utilization of the
strengths of Army organization and ethics.
(2) Mental health personnel assigned combat stress control duties are clearly
identified as members of a specific TOE unit. They may be organic members of
line medical units (such as the mental health section of the division's medical
support company or the corps' area support medical battalion), or they may be
members of a medical combat stress control unit which has a formal support
relationship with the line units (such as a medical detachment or medical
company, combat stress control).
(3) Combat stress control personnel work closely with the chain of command and
the chain of support in the context of the supported units' changing missions.
They work in the supported units' locations, or as close as is feasible under the
tactical conditions.
(4) Mental health/combat stress control personnel also work with the individual
soldiers and (in peacetime) with the soldier's family members. However, these
soldiers and families are considered valued members of the supported unit; they
are not labeled as patients or clients. Combat stress control personnel begin with a
presumption of normality (that the soldier [or family member] is a normal, wellintentioned human being). They presume that these soldiers or family members
are trying in good faith to master the sometimes excessive stressors of military
life and that they want to succeed. This presumption can only be displaced by a
thorough evaluation which proves the contrary, or by failure to improve after
sufficient expert treatment.
b. Army Medical Department combat stress control is proactive and prevention-oriented.
(1) Combat stress control personnel/units dedicate much of their time and
resources to activities which assist the commanders of units in controlling
stressors. They identify stress problems before they lead to dysfunction or stress
casualties. This early identification permits the retention and recovery of mildly
and moderately overstressed soldiers, in their units, on duty status.
(2) Even when providing reactive treatment to heavily overstressed soldiers who
are in crisis, combat stress control personnel continually look for the primary
causal factors (stressors). They work with the chain of command and the chain of
support to gain control of the stressors or control stress which may adversely
affect soldiers and their families. The objective is not only to help the afflicted
soldiers and return them to effective duty, but also to prevent future affliction in
others.
(3) Even when overcommitted to treating mass casualties, combat stress control
units remain alert and prepared to reallocate resources. When necessary, combat
stress control resources deploy to support units in forward areas. There, they
provide early preventive intervention for stressed soldiers and assist command to
gain control of the correctable stressors. The intent of early preventive
intervention is to -


Minimize the flow of battle fatigue casualties.
Provide treatment for and return to duty of soldiers.
Minimize the risk of future suffering and disability (prevent PTSD).
B-4. Organizational and Operational Concept for Army Medical Department Combat
Stress Control
a. Organic Mental Health Sections. Mental health personnel are organic to medical
elements of divisions, separate brigades, and the area support medical battalion.
(1) Division mental health sections have a psychiatrist, a social work officer, a
clinical psychologist, and seven behavioral science specialists. At least one
behavioral science NCO and one mental health officer should be allocated
routinely to work in each maneuver brigade.
(2) The area support medical battalion has a psychiatrist, a social work officer,
and eight behavioral science specialists. A behavioral science NCO may be
allocated to work with each area support medical company.
(3) Separate heavy brigade medical companies will have three behavioral science
specialists (currently no officer). Some SOF units have a clinical psychologist.
Armored cavalry regiments currently have no organic mental health personnel.
b. Mission of the Organic Mental Health Section. The mission of the organic mental
personnel is to provide command consultation, training, technical supervision, staff
planning, and clinical evaluation (neuropsychiatric triage). They must be mobile -- able to
travel to military units. They can provide brief forward treatment to small numbers of
cases during combat operations. Their assets are not sufficient to provide longer
treatment for large numbers of battle fatigue or neuropsychiatric casualties without
sacrificing their other critical preventive and staff functions.
c. Combat Stress Control on Today's Battlefield. On today's battlefield, each maneuver
brigade covers a larger and more fluid area and has greater fire power and responsibility
than did a WWII division. The Army operations concept makes the brigades even more
the basic warfighting echelon. Winning the first battles will be critical and may require
reconstitution of attrited units and rapid return of temporarily disabled soldiers to their
units. The organic division mental health personnel must be reinforced if cases are to be
restored in the brigade and division support areas. Separate brigades and armored cavalry
regiments will also require this reinforcement.
(1) The combat stress control organization must achieve a balance between prepositioning elements far forward and having other elements further to the rear.
The far forward teams provide consultation, triage, and immediate treatment. The
rearward teams support rear battle; these teams take the overflow and problem
cases from forward areas. The rearward teams are ready on short notice to
redeploy forward to the areas of greatest need, such as to the mass casualty or
reconstitution sites.
(2) The organic mental health sections are essential to provide the infrastructure
of mental health personnel who share familiarity and trust with unit leaders. These
factors are necessary for effective consultation and prevention.
(3) Under the combat stress control concept, the organic mental health section
provides the points of contact for reinforcing elements from corps-level combat
stress control units. These higher-echelon elements will deploy into the brigade,
division or corps area to assume the treatment role and assist in other functions.
The point of contact is essential for coordinating, updating, orienting and
facilitating the attachment of reinforcing combat stress control elements. A
combat stress control team which tries to join a unit during deployment, combat,
or reconstitution will be less effective unless it has mental health points of
contact. The mental health points of contact who have developed trust and
familiarity with the supported units are of great assistance in facilitating the
combat stress control support process.
d. Reinforcing Combat Stress Control Teams. The reinforcing combat stress control
teams are small, mobile teams made up of various combinations of the five mental health
disciplines. These teams may include a psychiatrist, social work officer, clinical
psychologist, psychiatric nurse, occupational therapist, and their enlisted specialists.
These teams will have their own tactical vehicles and bring a limited amount of supplies.
These combat stress control teams will come from either the medical companies or
medical detachments, combat stress control.
(1) The organizational concept for combat stress control packages the five subdisciplines (officers and enlisted specialists) of the mental health team into 4- or
11-person standard "modular teams." All combat stress control members have
basic skills to direct the management of generalized stress casualties while each
brings expertise to an area of specific responsibility, to be partially cross-trained
to others. Teams are combined into larger task-organized combat stress control
elements. The 4- or 11-person teams can be subdivided. Personnel may be crossattached between teams by their parent combat stress control unit to fit the
specific mission. The modified teams and task-organized combat stress control
elements will be tailored to make best use of available resources and the abilities
and experience of the individual team members.
(2) The combat stress control modular "teams" are as follows:


Combat stress control preventive team: Psychiatrist, social work officer,
and two behavioral science specialists. The team is allocated one truck
with trailer.
Combat stress control restoration team: Psychiatric nurse, clinical
psychologist, occupational therapy officer, two each of their enlisted
specialists, noncommisioned officer in charge (NCOIC), and a patient
administration specialist. This team is allocated two or three trucks with
trailers.
(3) The combat stress control preventive and combat stress control restoration
teams are incorporated into two units: medical detachment and medical company,
combat stress control.
e. Medical Detachment, Combat Stress Control.
(1) One combat stress control detachment normally supports one division or two
or three separate brigades or regiments.
(2) Each combat stress control detachment has three combat stress control
preventive teams and one combat stress control restoration team.
(3) The detachment normally sends combat stress control preventive teams
forward to the brigade support area while the combat stress control restoration
team staffs a "fatigue center" for restoration in the division support area or
forward corps. While in these areas, the detachment is under operational control
of the supported unit. Parts of teams may go forward to ambulance exchange
points or maneuver battalions not in contact.
f. Medical Company, Combat Stress Control.
(1) Each combat stress control company supports two or more divisions in the
corps area. Each combat stress control company has six combat stress control
preventive teams and four combat stress control restoration teams. These are
normally task-organized into two or more elements, ideally one task-organized
combat stress control element for each division supported. When total work load
allows, each task-organized element staffs a combat fitness reconditioning center,
collocated with a corps hospital; this may be augmented with elements of a
medical company, holding.
(2) Each task-organized element sends teams to provide consultation to corps
units and to reinforce area support medical companies when needed. It maintains
contact with the supported division mental health section and combat stress
control detachment in the divisions. The combat stress control company sends
teams forward to reinforce combat stress control elements as required.
(3) The combat stress control company headquarters collocates with either a
medical brigade, medical group, or area support medical battalion headquarters.
Combat stress control company support personnel are detailed to the taskorganized combat stress control elements. The combat stress control company
exercises command and control for its task-organized combat stress control
elements and for the combat stress control detachments which they support.
(4) The combat stress control company reports to and coordinates with the mental
health staff sections of the medical group and medical brigade. These small
headquarters staff sections advise and assist the combat stress control company
regarding the employment, support, and reallocation of combat stress control
assets to support the corps' area of operations.
g. Combat Stress Control in Army Operations.
(1) The combat stress control organization is designed to be utilized for war and
operations other than war. In war, their primary mission is prevention and rapid
return to duty of battle fatigue casualties. Teams must be available in sufficient
numbers, pre-positioned forward to react immediately, with rearward teams ready
to reinforce forward where battle fatigue casualties occur.
(2) In operations other than war, fewer combat stress control units are needed.
These combat stress control units are dispersed in support of division mental
health and corps units. The focus of their support is the prevention of misconduct
stress behaviors and perhaps treatment of substance misuse in theater.
(3) Prevention of PTSD by predeployment briefings, after-action debriefings, and
prehomecoming debriefings is a concern at all intensities.
(4) In peacetime, combat stress control detachments (both Active Component and
Reserve Component) must habitually train with the divisions they supported
during wartime (and/or with other similar divisions). The combat stress control
company must develop similar habitual relationships with units in their corps and
with the corps' combat stress control detachments. Combat stress control teams
should routinely augment organic mental health sections. They should work with
maneuver brigades/regiments which lack organic mental health to provide
preventive consultation and practice their combat role.
B-5. Combat Stress Control in the Continuum of Army Life
Combat stress control is not simply a medical responsibility. Fundamentally, it is a leadership
responsibility at all echelons. Since stress can have a monumental impact (positive or negative)
on the military, stress control activities should be a part of many Army activities. The stress
control effort must be concentrated in all three continuums of Army life which are -


Responsibility.
Location.
Mission.
A weakness or a gap at any point defined by those three continuums can cause weakness,
overload, or breakdown at points along the other continuums. All players along the dimensions
of responsibility, especially the mental health/ combat stress control personnel, need to achieve
and maintain the broad, three-dimensional system perspective.
APPENDIX C
UNITED STATES ARMY BANDS
C-1. Morale Support
Morale support is essential to the maintenance of our soldiers' will to fight and win. Morale and
esprit can be seriously undermined by the stress of battle, and they are the primary targets of
enemy psychological warfare. Consequently, they demand the continuing attention of
commanders at all levels.
C-2. Army Bands as Effective Tools
To meet these challenges, the commander needs an effective means at his disposal that
stimulates positive internal and external support for the Army's objectives. Army bands are
particularly effective tools at the commander's disposal in building, reinforcing, and maintaining
good morale and esprit, as well as countering enemy psychological operations (PSYOP).
C-3. Army Bands in Combat
During the US Army's past wars and conflicts, bands have ranged throughout the battlefield and
rear areas performing music. Today's Army bands are CSS units allocated to theater armies,
theater Army area commands, corps, divisions, theater defense brigades, selected major Army
commands, selected installations, and other selected commands. Army bands provide live music
for the troops whenever opportunities present themselves in peace and in war. Army bands are
combat-ready units capable of assisting commanders with prescribed missions in the same
manner that all CSS units provide support.
C-4. Mission
The mission of each Army band is specified in paragraph 1, Section I, of its TOE. This mission
may be slightly modified to fit local command needs and exigencies. Army bands promote
readiness and relieve stress by enhancing troop morale and unit esprit. They provide music for
troop gatherings and activities, military and religious ceremonies, and PSYOP.
C-5. Troop Gatherings and Activities
Army bands provide their most effective dimension of musical support at locations where troops
are gathered such as points of embarkation and debarkation, stand-down areas, dispersal areas,
hospitals and clearing stations, messing areas, training areas, and rest and recuperation centers.
By providing live music for entertainment at such areas, bands help commanders relieve the
stress of combat as well as counter loneliness, resignation, alienation, and other threats to the
morale and esprit of their soldiers.
C-6. Military Ceremonies
Army bands provide music for military ceremonies such as reviews, parades, memorial services,
and military funerals. This supports the objectives of the unit, building the common spirit that
exists between soldiers, raising the soldier above himself, and helping to forge a strong regard
for the honor and achievement of the unit by building enthusiasm, motivation, and continued
devotion to duty.
C-7. Religious Ceremonies
Army bands enhance worship and religious and memorial ceremonies on the battlefield. This
contributes to the strengthening of a soldier's moral values, his commitment to his unit and
fellow soldiers, and deepens his respect for the dignity of the individual embodied in his
nationhood. Participation in religious ceremonies by an Army band is in accordance with AR
165-1.
C-8. Music in Support of Psychological Operations
a. Army bands can contribute significantly to the combat effort when effectively
integrated into strategic, operational, and tactical PSYOP. Army bands can reduce the
effectiveness of enemy PSYOP directed toward friendly forces and supporting civilian
groups.
b. In meeting his commander's needs for music in combat, the band
commander tailors his unit to meet mission requirements. When manned
and equipped at current authorized allowances, Army bands are capable of
providing marching, concert, and popular (ethnic, cultural, or regional)
music performances.
APPENDIX D
THE UNIT MINSTRY TEAM"S ROLE IN
COMBAT STRESS CONTROL AND
BATTLE FATIGUE MINISTRY
D-1. Introduction
This appendix addresses the general role of the unit ministry team in the commander's program
of combat stress control and in battle fatigue ministry. The unit ministry team consists of a
chaplain and chaplain assistant assigned to units as far forward as the brigade, forward support
battalion, each maneuver battalion, and some combat support battalions. This team provides
immediate support to leaders in fulfilling their battle fatigue identification and intervention
responsibilities. The team also assists in training leaders to recognize battle fatigue symptoms.
Unit ministry teams provide training in basic counseling skills for enabling soldiers to talk about
their stress.
D-2. Effects of Stress
Negative effects of stress can be lessened when the soldier is prepared physically, emotionally,
and spiritually prior to combat. The unit ministry teams prepare soldiers to manage combat stress
with training before and during deployment. This training helps the soldier to draw upon spiritual
strength and share strength and confidence during intensive combat.
D-3. Team Relationship
The unit ministry team's relationship with the unit promotes trust with the soldiers. Embedding
the team in maneuver battalions enables it to respond readily to the needs of soldiers
experiencing combat stress and battle fatigue. A person-oriented resource, the team gives
religious support to battle fatigue casualties, especially soldiers having less severe difficulties
who have rapid replenishment potential.
D-4. Spiritual Values
Soldiers' inner resources are often based on their religious and spiritual values. In combat,
soldiers show more interest in their religious beliefs. When religious and spiritual values are
challenged during the chaos of combat, soldiers may lose sight of inner resources that sustain
them. The soldiers then become targets of fear, despair, hopelessness, and eventually, battle
fatigue casualties. They are also at risk for committing misconduct stress behaviors. The unit
ministry team is the primary resource available to soldiers experiencing these dilemmas and
seeking to refocus their spiritual values.
D-5. Team Support
Unit ministry teams provide preventive, immediate, and replenishing spiritual and emotional
support and care to soldiers experiencing battle fatigue.
a. Preventive. The religious support mission of the unit ministry team assists in
preventing battle fatigue and misconduct stress behaviors through establishment of a
presence within the unit. It is important for the unit ministry team to be present with
soldiers when the unit trains and when it deploys. The unit ministry team can be a
calming influence on soldiers; the team can help soldiers strengthen or regain values
important to them. Some of the things the unit ministry team does to prevent battle
fatigue and misconduct include the following:
o
o
o
o
o
o
o
o
Being present with the soldiers and deploying with the unit.
Providing opportunities for private and group prayer and worship.
Providing personal religious articles and materials.
Reading the scriptures with soldiers.
Providing sacraments as the situation allows.
Communicating with soldiers, allowing them to work through stress, fear, anxiety,
anger, and frustration.
Visiting soldiers in work and living areas.
Assisting soldiers and families prior to deployment with preparation for
geographical separation and an uncertain future through programs which
emphasize family strengths. This helps soldiers to know that their families are
cared for during deployment.
b. Immediate. The unit ministry team assists commanders in the identification of soldiers
experiencing battle fatigue. They work closely with the unit leadership and the medical
personnel in battle fatigue care. Chaplains and chaplain assistants are trained to recognize
the signs of battle fatigue and provide religious support to soldiers experiencing battle
fatigue. The unit ministry team establishes rapport with the soldier and assesses his
religious needs. The team then performs or offers the type of religious support designed
to provide the most comfort. This includes such things as the following:
o
o
o
o
o
Presence with the soldier.
Conversation and an opportunity to share fears, hopes, and other feelings.
Prayers: general prayers, prayers for the individual, or prayers for fallen
comrades.
Rites, sacraments, and ordinances as appropriate.
Reading from sacred scriptures.
c. Replenishing. Following an engagement, the unit may require reconstitution through
the addition of new personnel. The unit ministry team will find the surviving soldiers
may require a rebuilding of the emotional, psychological, and spiritual strength. During
this time, the unit ministry team may require assistance from a chaplain support team
(TOE 16500LA/B) or other available rear area unit ministry team assets. The team will
maintain its ongoing direct religious support functions which include the following:
o
o
o
o
o
o
o
o
o
Coordinating the availability of worship services, sacraments, rites, and services/
ceremonies honoring the dead.
Facilitating the integration of personnel replacements.
Facilitating the grief process through personal counseling and memorial services.
Reinforcing the soldier's sense of self-worth and hope.
Structuring opportunities for soldiers to talk about what they have experienced in
combat and facilitating integration of the combat experience into their lives.
Preparing for the next stage of battle.
Providing personal religious articles and materials.
Securing or providing denominational religious coverage in the unit or for other
units.
Participating in rebuilding the physical, emotional, and spiritual resources of the
unit.
The unit ministry team operates with a soldier-focused approach to religious support. The
spiritual dimension the team brings to the soldier's situation is an essential element in the
replenishment process. Religious support assists the soldier in achieving emotional and spiritual
wholeness.
D-6. Reintegration
Following the end of hostilities, the unit ministry team facilitates reintegration of the individual
soldier into family relationships and society at large. Many religious support functions remain
the same. Expanded religious support functions may also include the following:





Providing worship events for the entire unit.
Providing worship events for varied religious denominations.
Providing briefings which help soldiers recognize, prepare for, and master the stressors of
reunion with family.
Providing structured events to assist soldiers returning to family and civilian life.
Providing opportunities for soldiers to experience and understand the forgiving and
unchanging love of God.
APPENDIX E EXAMPLE LESSON PLAN
LESSON TITLE: IDENTIFY, TREAT, AND PREVENT BATTLE FATIGUE
COURSE PRESENTED TO: Officers, warrant officers, and NCO's at battalion, company and
platoon level of all divisional and nondivisional, active duty, Reserve and National Guard units.
PLACE: Classroom or field training site.
REFERENCES:
FM 21-20 Physical Fitness Training
FM 22-9 Soldier Performance in Continuous Operations
FM 22-51 Leaders' Manual for Combat Stress Control
FM 22-100 Military Leadership
FM 100-5 Operations
Unit Combat Mission Statement
Unit History
STUDY ASSIGNMENT: As directed by the instructor or commander.
STUDENT UNIFORM AND EQUIPMENT: As directed by the instructor or commander.
TOOLS, EQUIPMENT, AND MATERIALS:
GTA 21-3-4, Battle Fatigue, Normal, Common Signs, What to Do for Self and Buddy
GTA 21-3-5, Battle Fatigue, "More Serious" Signs: Leader Actions.
GTA 21-3-6, Battle Fatigue, Company Leader Actions and Prevention.
PERSONNEL: One Instructor.
INSTRUCTIONAL AIDS: Chalk, chalkboard, eraser, and lectern.
TROOP REQUIREMENTS: None.
TRANSPORTATION REQUIREMENTS: None.
RISK ASSESSMENT LEVEL: As directed by the instructor or commander.
SAFETY REQUIREMENT: As directed by the instructor or commander.
METHOD OF INSTRUCTION: Conference/discussion with examples from real situations.
I. INTRODUCTION
A. Opening Statement. During heavy fighting in past wars, the Army usually had one
battle fatigue casualty for every three to five soldiers evacuated with wounds. In the 1982
Lebanon Crisis, one Israeli armor unit had one case of battle fatigue for every one
wounded in a desperate night action. Israeli CSS soldiers (for example, truck drivers,
ordinance technicians) became stress casualties when they saw what modern weapons do
to human bodies, even though they themselves were not under attack. However, in elite
units (such as Airborne and Rangers in WWII), less than one battle fatigue casualty for
every ten wounded occurred, even in extremely intense or prolonged fighting.
This teaching applies specifically to your units and your missions in any level of combat
intensity, whether you are combat arms, combat support, or CSS. History shows that
most battle-fatigued soldiers can be restored to duty quickly if they rest close to their
units and are treated positively as soldiers, not as weaklings, cowards, or sick patients.
This restoration requires planning and coordination. If they are evacuated too far to the
rear, many may never recover. In the continuous battlefield of war, even the short-term
loss of so many trained, combat-experienced soldiers could be disastrous. The Army
initiated this combat stress control training program to ensure that all senior NCOs and
company-grade officers know what to do about battle fatigue (how to identify it, how to
treat it, and how to prevent it). You, in turn, are responsible for teaching your
subordinates what they need to know to control battle fatigue and accomplish the
mission.
B. Objectives.
1. Enabling Learning Objectives.
a. State the definition of battle fatigue.
b. State the normal, common signs and the warning (more serious) signs of
battle fatigue.
c. List the leaders' treatment of normal, common signs and warning signs
of battle fatigue.
d. Define mild (duty), moderate (rest), severe (hold/refer) battle fatigue in
terms of where each is sent.
e. State the principles of preventing battle fatigue.
2. Terminal Learning Objective. Discuss leaders' responsibility for identifying,
treating, and preventing battle fatigue as discussed and identified in FM 22-51.
C. Class Procedure and Lesson Tie-in. Lecture. This lecture pertains to leaders'
responsibility to identify, treat, and prevent battle fatigue. Additional subject areas
pertaining to leaders' responsibilities will be discussed in subsequent classes.
II. EXPLANATION
A. Definition of Battle Fatigue.
1. Battle fatigue is a broad group of physical, mental and emotional signs that
naturally result from the heavy mental and emotional work of facing danger under
difficult conditions. Its symptoms have in common that they..
a. Feel unpleasant.
b. May interfere with mission performance.
c. Improve with reassurance, rest, replenishment of physical needs, and
activities which restore confidence.
2. Battle fatigue is the US Army's official doctrinal term for combat stress
behaviors which fit the definition given (AR 40-216).
NOTE: The term battle fatigue is to be used whether the signs occur in a new soldier or in a
veteran after months of combat. It is to be used whether the signs start before shooting starts,
during the action, or in a letdown period before further action. It can occur in headquarters and
CSS soldiers who are not themselves under fire but are performing demanding duties under the
threat of danger or serious failure.
3. There are differences among the terms battle fatigue, stressors, combat stress
and other combat stress behaviors.
a. Stressors are the causes of combat stress. They are events or situations
which require a change, create internal conflict, or pose a threat. Combat
stressors are any stressors which occur in the context of performing one's
combat mission (whether under fire or not). For example:
(1) A 155 mm round exploding 100 meters away.
(2) Your platoon leader being wounded.
(3) Receiving a letter from wife or girlfriend which says she is
going away with another man.
(4) A windchill factor of -10 degrees F.
A stressor plus the soldier's perception of that stressor causes
stress.
b. Combat stress is the internal psychological and physiological process
within the individual soldier of reacting to and dealing with the combat
stressors. Stress depends much on the individual's appraisal of the stressor
and its context. For example:
(1) Was that 155 mm round you heard an enemy one catching you
in the open, or was it the final round of friendly protective fire just
as the enemy is about to overrun you?
(2) Have the class think of examples for each of the other stressors
listed above which would greatly influence the resulting stress.
Combat stress at any given time is the result of many stressors: fear
of death, fear of failure, other intense painful emotions like grief
and guilt, uncertainty, boredom, worries about what is happening
back home, and the many physical and mental demands of combat
duties. Combat stress is the cause of battle fatigue.
c. Combat stress behaviors are the observable behaviors which the soldier
shows as the result of the internal stress (either to overcome the stress, to
escape it, to make it more tolerable, or to have a side effect of it). Battle
fatigue is one group of combat stress behaviors. There are also other
combat stress reactions.
(1) Some are positive (like alertness, exceptional strength and
endurance, loyalty to comrades, and acts of heroism).
(2) Some are negative (like malingering, self-inflicted wounds,
committing criminal acts, abusing drugs, going absent without
leave, or refusing to obey orders). These others are not called battle
fatigue, although battle fatigue may be present along with them if
they really are reactions to combat stress. These are misconduct
stress behaviors.
(a) The misconduct may or may not interfere with specific
combat tasks and may even be done by otherwise excellent
soldiers, but it is harmful to discipline, is illegal and is
contrary to the UCMJ.
(b) The misconduct stress behaviors can be prevented by
good leadership, but once they occur, they require
administrative action, specific medical or surgical
treatment, and/or punishment. For example, malingerers
must be counseled and returned to their units. Soldiers with
self-inflicted wounds require line-of-duty investigations
which may warrant disciplinary action. If line-of-duty is no,
these soldiers may incur all cost associated with their
treatment, hospitalization and recovery. Soldiers who desert
or violate the Law of Land Warfare must be punished.
(3) Combat stress or good combat performance do not excuse
criminal acts. Misconduct stress behaviors must be prevented.
d. The difficult combat conditions (stressors) which cause battle fatigue
may include sleep loss, dehydration, muscular fatigue, and such physical
stressors as heat, cold or noise. However, these are not necessarily the
causes.
e. Like physical fatigue, battle fatigue can develop at either a slow or fast
rate. Its speed of onset depends on the intensity and duration of the stress
and on the soldier's prior training, experience, and fitness.
f. Battle fatigue usually improves when a soldier can rest and replenish
himself with food, water, and sleep. It is just as important to restore his
self-confidence.
g. Battle fatigue is a simple, common sense name for a natural, common
condition which is not a medical or psychiatric illness.
NOTE: You may explain to the class that experience from WWI or WWII shows that soldiers
tend to develop signs that are harder to manage if dramatic terms like "psych casualty" or "battle
shock" are used. Fatigue is a better word than exhaustion. It applies to the mild as well as to the
heavy cases and implies that the condition improves quickly.
4. The terms stress fatigue or conflict fatigue can be used for the same signs
occurring under stressful conditions where no actual combat is involved. For
example, stress fatigue is common among officers and NCOs at the National
Training Center. All the information in this lesson can and should be used there
and in garrison.
B. Normal, Common Signs and Warning Signs of Battle Fatigue.
1. The following are facts about the normal, common signs:
a. Most soldiers have some of these signs some of the time (before, during
and after combat or danger).
b. Most soldiers have some of these signs often, yet they still fight well
and perform all essential duties.
c. All soldiers, especially leaders, need to know that these are normal and
common so they will not worry about them too much.
d. Key point: These signs are so normal that you should look closer at
soldiers who never show any. Maybe they are just controlling their stress
and fear exceedingly well. But maybe they do not realize the danger. Or,
maybe the absence of the normal response is a warning sign of more
serious battle fatigue.
e. The normal, common signs include some physical and some
mental/emotional signs. Company and platoon leaders must ensure that
squad and section leaders familiarize every soldier with these signs.
NOTE: Direct the class to look at page 2 of GTA 21-3-4 (handout 1) which shows the normal,
common signs. You may make transparencies if you wish. If time permits, stimulate discussion.
Draw on the experience of any combat veterans or those who have taken part in highly
competitive or dangerous sports or in training such as parachuting or rappelling. Make the
following key points:


Most of the physical signs are the result of having an increased amount of adrenaline in
the bloodstream. These physical signs are likely to worsen when a person cannot be
physically active or when he stays keyed up for a long time without resting.
The mental signs are natural in situations where high stress, fear, or fatigue temporarily
overload the brain's ability to process information. The emotional signs are likely to
occur because bad things do happen in combat to cause normal grief, guilt, resentment,
and doubt.
2. The following are facts about the warning signs:
a. Warning means that these are signs which deserve special attention and
leadership action.
b. Warning signs do not necessarily mean that the soldier needs to be
relieved of duty or be evacuated as a casualty. Immediate action by
leaders, buddies or the soldiers themselves may be all that is required.
c. Any of the normal, common signs become warning signs if they
interfere with essential performance even after the soldier's buddies or
leaders have taken action to help them.
d. Normal, common signs should be considered warning signs if they do
not improve when the soldier gets a good chance to rest. However, these
signs may not go away completely while the war continues. The soldier
may have to learn to live with some of them. Some of the signs may even
continue for a time after the soldier's return from combat to his home.
e. The signs must be considered in relation to a soldier's usual way of
reacting. Take them more seriously if they come as a big change from how
that soldier usually reacts to danger or interacts with other people.
NOTE: Give examples, such as the following:


New troops being startled at the loud sound of friendly outgoing artillery is normal and
common. It is a warning sign in experienced veterans.
It is a warning when the soldier who is usually quiet turns rowdy and complains. It is a
warning when the unit complainer turns quiet.
NOTE: Direct the class to page 3 of GTA 21-3-5 (Handout 2). Alternatively, you may make
transparencies. Be sure that the class understands that some of the warning signs differ from the
normal, common signs only in degree or the situation. Give examples such as the following:


Fidgeting and trembling are normal and common, while constantly moving around or
obvious shaking are warning signs.
Trembling of the hands before action is normal and common, but the same trembling
while performing a critical combat task is a warning sign if it may result in mission
failure.
NOTE: Some of the signs are always warning signs in the sense of requiring some immediate
leader action. They may be a sign of dangerous physical or mental illness. For example:

Seeing or hearing things which aren't there is always a warning sign. It may endanger the
mission or be a sign of serious illness. However, seeing things which are not there does
occur often in otherwise perfectly normal people when they go a long time without sleep.
They recover when they get sleep and may not necessarily have to leave the unit or get
medical evaluation.
C. Leaders' Treatment of Normal, Common Signs and Warning (More Serious)
Signs of Battle Fatigue.
NOTE: This part of the lesson plan concerns what should be taught to team, section, squad and
platoon leaders about treating battle fatigue. These intervening actions for battle fatigue by junior
leaders may require some soldiers to leave the small unit. These actions may require that soldiers
be sent to locations where the more senior officer, NCO, or medic makes the decision pertaining
to the soldiers' duty status. Company-level leaders will be familiar with treating battle fatigue
and know the intervening actions they implement at their level. Company-level leaders are
responsible for teaching and supervising treatment for common and warning signs of battle
fatigue.
1. What soldiers should do for self and buddy when showing signs of battle
fatigue is outlined in GTA 21-3-4 (Handout 1). If time permits, familiarize the
class with pages 3 and 4 or use a transparency made from that section to show
what is covered. Senior leaders should ensure that junior leaders review this
material with their soldiers and have them practice it regularly.
2. Leader actions for normal, common signs (which also should be used for
warning signs) are outlined in GTA 21-3-5 (Handout 2). Senior leaders should
review the material with junior leaders and have them practice it regularly.
NOTE: Direct the class to pages 4 and 5 of GTA 21-3-5 (Handout 2) or use transparencies.
Stimulate discussion about any techniques which may be unfamiliar. Make the following points:


These actions are basic leadership techniques with which most of you are already
familiar.
These actions are also preventive; they reduce the combat stress that causes battle fatigue
and help soldiers cope with the normal, common signs to make them less likely to
become more serious.
3. Leaders' actions for warning signs are also outlined in GTA 21-3-5 (Handout
2). This information should be reviewed with junior leaders.
a. These step-by-step actions safeguard the unit's mission and its members,
get the battle-fatigued soldier to a safer place, and begin the process of
restoring the soldier's confidence. (At least the actions do not undermine it
further.)
b. One recommended action is to avoid taking a soldier's weapon away
unless he seems so unreliable that he may use the weapon dangerously.
The soldier's self-identity as a soldier who is trusted and needed by
comrades is the strongest factor pulling him back from battle fatigue to
effective duty. Taking his weapon away gives the message "We don't trust
you" or You are not a good soldier," unless you counteract this message
by what you say when you take the weapon.
NOTE: If time permits, stimulate discussion about what might be involved to"do whatever must
be done to control the soldier" in order to protect the mission and the unit. Consider different
types of situations. Point out that crazy, dangerous, and violent behavior is unusual in pure battle
fatigue but may occur more often in other types of combat stress behaviors, especially those
involving drug abuse.
c. What leader and buddies do and say on the spot has an extremely
important effect on how quickly soldiers recover and even on whether
they ever recover. The right words may make extremely serious warning
signs of battle fatigue get better in minutes or even seconds. Even if they
do not work immediately, they help soldiers recover as quickly as
possible.
4. Junior leaders' actions bring soldiers who fail to improve to the point where a
more senior officer, NCO, and/or medic must make the decision whether these
soldiers stay in the platoon or company or be sent elsewhere. This requires that
battle fatigue cases be classified as duty, rest, or heavy. Note that duty, rest, and
heavy were originally classified as mild, moderate and severe in the 1986 version
of GTA 21-3-6. They have been changed to duty, rest, and heavy in the 1991
updates of those GTAs to conform with FM 22-51.
NOTE: Explain that the section/squad leader does not need to know how to make this
classification. The first sergeant, company commander, and company medic must know it. They
should teach it to the platoon leaders, platoon sergeants, and platoon medics. Direct the class to
page 2 of GTA 21-3-6 (Handout 3) or use transparencies made from that page.
D. Duty, Rest, and Heavy Battle Fatigue
1. Cases of battle fatigue are classified according to where they can be managed.
The three classifications are outlined in GTA 21-3-6 (Handout 3) and are defined
below.
a. Duty. The soldier remains in the small unit (section or platoon) to rest
and be restored to full duty.
b. Rest. The soldier cannot remain in the small unit and must be sent to
another supporting unit for temporary rest and replenishment, but not
necessarily to a medical unit.
c. Heavy. The soldier must be sent to a physician, physician assistant, or
mental health officer for evaluation.
NOTE: Tell the class that the labels duty, rest, and heavy should be thought of as nothing more
than "tickets" which say where the soldier should go at this time. They are temporary triage
categories (like immediate, minimal, delayed, and expectant in surgical triage). The following
points (or criteria) are used to decide where the soldier can be treated.
2. Duty applies to soldiers who -a. Show normal, common signs, feel uncomfortable, but are 100 percent
effective.
b. Show warning signs and may be partially or even completely
ineffective, but are not an unacceptable risk or burden to the unit in the
tactical situation.
c. Do not need urgent medical evaluation.
3. Rest applies to soldiers who must be sent to another nonmedical unit for a
period of rest.
a. They are too much of a risk or burden to stay with their own unit at this
time, given its tactical mission.
b. The soldiers' own units cannot provide a sufficiently safe, stable
environment for rest and replenishment at this time.
c. The soldiers are not too disruptive or potentially dangerous for a unit
with a less demanding mission at this time.
d. They do not need urgent medical evaluation to rule out some possible
serious physical cause or illness for the signs they are showing.
NOTE: Point out that whether a case of battle fatigue is called duty or rest depends more on the
tactical situation, mission, and resources of the small unit than it does on the signs the soldier is
showing. A unit which is just being pulled back into reserve can keep a soldier who might have
to be left behind if the unit were just leaving for action behind enemy Iines. Use examples from
your type of unit.
4. Heavy applies to any soldier with more serious warning signs who fits within
one or both of the categories below.
a. The soldier is too burdensome, disruptive, or possibly dangerous to keep
in the small unit or in any available nonmedical support unit at this time.
b. The soldier's symptoms could be due to a physical cause which may
need urgent medical/surgical treatment (for example, head or spine injury,
drug abuse).
NOTE: Heavy is now being used instead of severe because too many people kept confusing
severe with the more serious signs and reading into the word more negative meaning than it
deserves. The difference between rest and heavy is influenced more by the kinds of signs the
soldier is showing than was the difference between duty or rest, although the availability of other
CSS units can still affect this classification.
NOTE: Once the soldier reaches the medical system, they subdivide heavy into refer (meaning
send to the next echelon medical facility for evaluation) and hold (meaning hold for treatment at
this medical facility). However, there is no need to explain this distinction to nonmedical
audiences since it applies only after the soldier has reached and has been evaluated by the
physician or physician assistant.
5. There is no easy rule for deciding whether a warning sign makes the soldier a
case of duty, rest, or heavy battle fatigue. That will require judgment based on
what the leader and, perhaps, the unit medic know about the individual soldier:
what has happened to the soldier; how the soldier responds to helping actions;
what is likely to happen to the unit next; and what resources are available to the
unit. Any warning sign that can be listed in a few words may be duty battle
fatigue in one case, be rest in another, and be heavy in a third case.
6. Signs which would usually cause the case to be sorted as heavy include the
following:
a. Dangerous, threatening behavior which is not just a disciplinary
problem.
b. Hallucinations and delusions not explained by sleep loss.
c. Serious memory loss.
d. Extreme pain.
e. Loss of a major physical function, such as vision or the ability to move
an arm.
f. Complete unresponsiveness; not moving or answering at all.
NOTE: Any of these cases might still be classified as rest or even as duty if the signs occur in
response to extreme stress and clear up quickly.
7. The heavy classification does not necessarily mean that a soldier is less likely
to recover or will take longer to recover than cases classified as duty or rest.
8. Company leaders' actions for duty and rest battle-fatigued soldiers are outlined
in GTA 21-3-6 (Handout 3). Company commanders, first sergeants and company
medics should know and practice them and teach them to platoon-level leaders
and medics.
NOTE: Direct the class to Handout 3, page 2, or use the transparencies made from pages 2 and
3, or briefly discuss the list. You should adapt these recommendations to your unit. Stimulate
discussion on how it needs to be adapted. For example:


The supporting units where soldiers can be rested will be different for maneuver
companies in an armor or a light infantry battalion, for an artillery battery, for a dispersed
corps-level signal company, or for a maintenance or a transportation company.
Options include resting the soldier in another platoon of your company; in another line
company in the battalion; or at the battalion headquarters and headquarters company in
the field trains.

Some small detachments may not have first sergeants or platoon/company/battalion
organization. They may be attached to other units for support. Determine where to rest
battle-fatigued soldiers in your situation.
9. The following are key points:
a. The first sergeant or NCOIC has to take the soldiers and find them a
safer, quieter place to rest and work for a day or two. Note that
instructions for the leader of the unit who receives the soldiers temporarily
are included in GTA 21-3-5, page 6.
b. If the soldier's small unit cannot wait for the first sergeant/NCOIC to
take the soldier, it may be necessary to evacuate to the supporting medical
element. If so, every effort should be made there to remove the soldier
from medical channels to a nonmedical unit for further rest,
replenishment, and reassurance.
c. A first sergeant/NCOIC who cannot find a suitable support unit can try
to arrange a place to sleep at a medical unit which has empty cots. This
alternative is not preferred, and the soldier must understand he is not a
patient, just a tired soldier.
d. The soldier must remain accounted for and not get lost in the shuffle.
There must be a positive plan to return the soldier to the original unit in a
short time, and the soldier must know this.
e. Every reasonable effort should made to maintain personal contact
between the soldier and the original unit.
10. Leader actions for heavy battle-fatigued soldiers are the same as for the rest
battle-fatigued except that the soldiers are evacuated medically, as soon as
possible to be examined by a physician or physician assistant.
a. They may be successfully treated and released within hours (as duty or
rest battle fatigue), or may be held there for rest and treatment for a day or
two, or may be evacuated further to the rear. What happens depends on
their signs and the medical unit's situation.
b. If treated close to their units, 50 to 85 percent (average 75 percent) of
heavy battle fatigue casualties return to duty within 1 to 3 days. About 15
to 20 percent more may return to other duty (usually in other units) in 1 to
2 weeks. Only 5 to 10 percent have to evacuated home, and they usually
have other problems besides battle fatigue.
c. However, if evacuated too far too fast, few battle-fatigued soldiers
return to duty. Many may remain permanently disabled.
11. Recovered battle-fatigued soldiers who return to their units and are welcomed
there do not have a higher rate of battle fatigue than other soldiers. They are less
likely to break again (or to be killed or wounded) than is a new replacement who
is a stranger in the unit.
NOTE: Emphasize to the class that a good soldier will be good again. A new soldier who
becomes a battle fatigue casualty deserves another chance. Being new to combat and a stranger
in the unit are two high-stress/high-risk factors. These factors have been partially overcome if
that soldier returns to the same unit and is welcomed there. But also emphasize the following
point and stimulate discussion on how it should be handled.
12. Someone who has always been a poor soldier is not going to be made into a
good one simply by treatment for battle fatigue. The soldier may need to be
reassigned to some other job or unit (or be discharged as unsuitable).
E. Basic Principles of Preventing Battle Fatigue.
1. While the average ratio of battle fatigue casualties to wounded in action is one
for every three to five, elite units consistently have fewer that one for ten
wounded. We cannot prevent battle fatigue in highly stressful combat; however,
we can prevent battle fatigue casualties who require treatment in the medical
system.
2. GTA 21-3-6 (Handout 3) shows factors that increase battle fatigue casualties
and leaders' actions to prevent them. These should be taught by battalion and
company leaders to their platoon leaders.
3. The following are key principles for reducing stress of combat and preventing
battle fatigue casualties:
a. Encourage unit cohesion by integrating new replacements quickly,
assigning buddies, and using other team-building techniques. Unit
cohesion is the personal trust and loyalty of soldiers who have worked
together to overcome hardship and danger to achieve a common objective.
b. Stabilize the home front by helping soldiers resolve their home front
problems. An Israeli study found that having uncertainties at home was the
strongest factor which distinguished soldiers who became stress casualties
form those who were decorated for valor. Unit cohesion is the second
strongest.
c. Instill unit pride by honoring historical examples of initiative, endurance
and resilience, of overcoming heavy odds, and of self-sacrifice leading to
triumph. This is needed to give direction and hope to the cohesive unit so
that it does not become preoccupied solely with the survival and comfort
of its members.
d. Assure physical fitness. This must enhance muscle strength and agility
as well as endurance through a regular training program. Not being
physically fit almost guarantees battle fatigue when the going gets rough.
e. Conduct tough, realistic training that is as much like the combat mission
and environment as possible (sights, sounds, pace, confusion, fatigue,
discomfort and feedback). Soldiers' first exposure to combat, to enemy
weapons and tactics, and to strange, hostile climates produces battle
fatigue.
f. Practice casualty care and evacuation routinely. Everyone must know
lifesaving techniques for self and buddy. Talk about the possible loss of
leaders and comrades. Prepare junior leaders (and yourself) to take over.
This way soldiers know that they can receive immediate care and the chain
of command will not break.
g. Plan and practice sleep discipline. Plan ahead to make sure all soldiers
get enough sleep, especially leaders and those with critical tasks. Sleep
discipline means reviewing sleep as a resource to allocate to soldiers just
like water, food, ammunition and fuel.
III. SUMMARY
A. When in combat, you, the leader, must try to conserve the soldiers' strength and wellbeing with food, water, shelter, hygiene, medical care, and rest. In contrast to the training
situation, you do not deliberately seek hardship. When you must accept it because of
circumstances or better accomplishment of the mission, you will explain the reasons to
the troops. And, because you have trained hard together, you can remind the soldiers of
how all of you suffered in training and still accomplished the mission just to prepare for
this kind of combat situation.
B. Use the three handouts. They are available to the US Army Training and Audiovisual
Support Center. They are intended for leaders to use as aids in opportunity training for
their subordinates during field exercises. They will also serve as a reminder (checklist) in
mobilization and combat.
1. GTA 21-3-4 (Battle Fatigue, Normal, Common Signs, What to do for Self and
Buddy) is intended for all soldiers, especially the junior enlisted.
2. GTA 21-3-5 (Battle Fatigue, "More Serious" Signs: Leader Actions) is
intended for all leaders, especially those at team, squad, section, and platoon
level.
3. GTA 21-3-6 (Battle Fatigue, Company Leader Actions and Prevention) is
intended for platoon leaders and above.
GLOSSARY
ABBREVIATIONS AND ACRONYMS
AIDS acquired immunodeficiency syndrome
AMEDDC&S Army Medical Department Center and School
AR Army Regulation
attn attention
AWOL absent without leave
BAS battalion aid station
C4I command, control, communications, computers and intelligence
CAARNG California Army National Guard
CIP Command Information Program
COHORT cohesion, operational readiness training
COMMZ communications zone
CONOPS continuous operations
CONUS continental United States
CSS combat service support
DA Department of the Army
DNBI disease and nonbattle injuries
DOW died of wounds
DSM III-R Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised
EPW enemy prisoner(s) of war
FID Foreign Internal Defense
FM field manual
G1 Assistant Chief of Staff (Personnel)
G2 Assistant Chief of Staff (Intelligence)
G3 Assistant Chief of Staff (Operations and Plans)
G4 Assistant Chief of Staff (Logistics)
G5 Assistant Chief of Staff (Civil Affairs)
GTA Graphic Training Aid
HN host nation
IDAD Internal Defense and Development
KIA killed in action
MIA missing in action
MOPP mission-oriented protective posture
MRE meal(s), ready to eat
NBC nuclear, biological, and chemical
NCA national command authority
NCO noncommissioned officer
NCOIC noncommissioned officer in charge
NEO noncombatant evacuation operation
NYDN not yet diagnosed, nervous
PSYOP psychological operations
PTSD post-traumatic stress disorder
PW prisoner(s) of war
R&R rest and recuperation
S1 Adjutant
S2 Intelligence Officer
S3 Operations and Training Officer
S4 Supply Officer
S5 Civil Affairs Officer
SOF special operations forces
SPRINT Special Psychiatric Rapid Intervention Team
STD sexually transmitted dieases
SUSOPS sustained operations
TOE table of organization and equipment
TSOP tactical standing operating procedure
UCMJ Uniform Code of Military Justice
US United States
WIA wounded in action
WWI World War I
WWII World War II
REFERENCES
SOURCES USED
These are the sources quoted or paraphrased in this publication.
Army Publications
AR 310-25. Dictionary of United States Army Terms (Short Title: AD). 15 October 1983.
(Reprinted with basic including Change 1, May 1986.) AR 310-50. Authorized Abbreviations,
Brevity Codes, and Acronyms. 15 November 1985. DA Pam 25-37. Index of Graphic Training
Aids (GTA). 1 July 1991. FM 12-50. US Army Bands. 6 September 1991. FM 16-1. Religious
Support Doctrine: The Chaplain and Chaplain Assistant. 27 November 1989. FM 22-5. Drill
and Ceremonies. 8 December 1986. FM 22-102. Soldier Team Development. 2 March 1987. FM
100-2-1. Soviet Army Operations and Tactics. 16 July 1984. FM 100-37. Terrorism
Counteraction. 24 July 1987.
DOCUMENTS NEEDED
These documents must be available to the intended users of this publication.
Multiservice Publications
FM 100-20. Military Operations in Low Intensity Conflict. AFP 3-20. 5 December 1990.
Army Publications
AR 40-216. Neuropsychiatry and Mental Health. 10 August 1984. *AR 165-1. Chaplain
Activities in the United States Army. 31 August 1989. *FM 8-42. Medical Operations in Low
Intensity Conflict. 4 December 1990. FM 21-20. Physical Fitness Training. 28 August 1985.
*FM 22-9. Soldier Performance in Continuous Operations. 8 December 1983. *FM 22-100.
Military Leadership. 31 July 1990. FM 25-101. Battle Focused Training. 30 September 1990.
*FM 90-10. Military Operations on Urbanized Terrain (MO UT) (How to Fight). 15 August
1979. *FM 90-10-1. An Infantryman's Guide to Urban Combat (How to Fight). 15 August 1979.
*FM 100-5. Operations. 5 May 1986. GTA 21-3-4. Battle Fatigue, Normal, Common Signs,
What to do for Self and Buddy. June 1986. GTA 21-3-5. Battle Fatigue, "More Serious" Signs:
Leader Actions. June 1986. GTA 21-3-6. Battle Fatigue, Company Leader Actions and
Prevention. June 1986.
*This source was also used to develop this publication
Nonmilitary Publications
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Third
Edition, Revised. Washington, D.C.: American Psychiatric Association, 1987.
READINGS RECOMMENDED
These readings contain relevant supplemental information.
Army Publications
DA Pam 600-63-10. Stress Management Module for "Fit to Win" Program. September 1987.
FM 8-10-4. Medical Platoon Leaders' Handbook. 16 November 1990. Mullins, W.S. and Glass,
H.A., eds. The Medical Department of the US Army, Neuropsychiatry in World War II (1973).
Overseas Theaters, OTSG, Department of the Army Washington, D.C. The Medical Department
of the US Army in The World War 10 (1920). Neuropsychiatry, War Department, Washington,
D.C. Summers, Harry G. Jr. On Strategy, The Vietnam War in Context. Carlisle Barracks,
Pennsylvania: US Army War Department, 1981.
Nonmilitary Publications
Cable, Larry. Conflict of Myths: The Development of American Counterinsurgency Doctrine and
the Vietnam War. New York: New York University Press, 1986. Belenky, Gregory, ed.
Contemporary Studies in Combat Psychiatry. New York: Greenwood Press, 1987. Du Picq,
Ardant. Battle Studies, trans. John N. Greely and Robert C. Cotton. (Harrisburg: Military:
Military Service Publishing Company, 1947.) Fanon, Frantz. The Wretched of the Earth. New
York: Grove Press, First Evergreen Black Cat Edition, 1968. Gifford, R.K. and Tyler, M.P.
"Consulting in Grief Leadership--A Practical Guide." Disaster Management 2, No. 4(1990).
Holmes, Richard. Acts of War: Behaviors of Men in Combat. New York: Free Press, 1985.
Home, Alistair. A Savage War of Peace. New York: Viking Press, 1978. Kellet, Anthony.
Combat Motivation: The Behavior of Soldiers in Battle. Boston: KluerNijhoff, 1982. Marshall,
S.L.A.. Bringing Up the Rear. Presidio Press, 1979. Swank, Roy L., and Marchand, Walter E.
"Combat Neurosis." Archives of Neurology 55 (1946): 236-46.